Columbia  ^nibet^ittp 

mtheCitpotHtUi^ork 


^AtUvmtt  SItbrarg 


Digitized  by  tine  Internet  Arcinive 

in  2010  witii  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/newmanualofsurgeOOochs 


Ol'EKATTOX    FOK    THE    ELIMINATION     OF   'J'HK    AsC     KInDInO,     I'kaNSVKKSE    AM)    DeSCEXDIXO    (  OLOX 

FOR   THE  Relief  of  Intestinal  Stasis. —  (Original  Drawing) 


'  "ivrr. 


A  NEW 

Manual  of  Surgery 

CIVIL  AND  MILITARY 


BY 

ALBERT  J.  OCHSNER,  B.S..  M.D.,  F.R.M.S.,  LL.D..  F.A.CS., 

Professor  of  Clinical  Surgery,  Medical  Department,  University  of  Illinois; 
Surgeon-in-Chief  of  Augustana  and  St.  Mary's  Hospitals,  etc.,  Cliicago. 

AND 

NELSON  M.  PERCY,  M.D.,  F.A.C.S., 

Associate  Professor  of  Clinical  Surgery,  Medical  Department,  University  of  Illinois;  Attending 
Surgeon,  St.  Mary's  Hospital;   Attending  Surgeon,  Augustana  Hospital,  etc.,  Chicago. 


FIFTH  EDITION— REVISED  AND  ENLARGED 


COMPLETE  IN  ONE  VOLUME 


FULLY  ILLUSTRATED 


CLEVELAND  PRESS 

CHICAGO 

1917 


Copyright  1917 

by  the 

CLEVELAND  PRESS 

All  rights  reserved 


0c3 


PREFACE  TO  THE  FIFTH  EDITION 

During  the  past  two  years,  since  the  appearance  of  the  very  largely  revised 
fourth  edition,  the  changes  in  surgical  practice  have  been  confined  to  a  large 
extent  to  the  practice  of  military  surgery,  ai^d  it  has  seemed  wise  to  add  a 
considerable  amount  of  material  in  a  special  chapter  on  this  subject. 

We  have  been  able  to  still  further  confirm  our  former  judgment  regarding 
many  methods  which  we  saw  fit  to  recommend  in  former  editions.  We  espe- 
cially wish  to  insist  upon  the  fact  that  we  make  no  claim  in  this  or  in  any  of 
the  previous  editions  for  originality  or  priority  for  any  of  the  methods 
described,  for  all  of  which  we  are  indebted  to  former  authors  of  books  or  of 
articles  in  periodicals  and  to  our  personal  observation  of  the  surgical  work 
of  our  friends  in  this  country  and  abroad. 

We  especially  wish  to  thank  Dr.  0.  E.  Nadeau  for  the  great  amount  of 
assistance  he  has  given  us  in  the  production  of  the  present  volume. 

A.  J.  0. 
N.  M.  P. 

PREFACE  TO  THE  FOURTH  EDITION 

The  time  that  has  passed  since  the  publication  of  the  third  edition  has  been 
especially  rich  in  our  clinical  experiences,  both  in  our  own  surgical  activity 
and  in  visits  to  other  clinics  in  this  country  and  abroad,  which  seems  a  reason- 
able basis  for  issuing  a  fourth,  revised  edition  of  this  work.  Assurance  is  given 
that  changes  have  all  been  made  after  careful  study  and  personal  applications 
of  the  methods  herein  recommended. 

As  in  each  of  the  three  former  editions  so  also  in  this  have  we  made  per- 
fectly plain  which  methods  we  have  tried  for  a  sufficient  period  to  give  a 
relatively  final  judgment,  and  which  are  still  under  observation. 

There  is  no  claim  as  to  originality  or  priority  for  any  of  the  methods  herein 
described,  neither  is  particular  credit  given  to  the  originators  for  the  reasons 
stated  in  the  preface  to  the  first  edition. 

We  wish  to  acknowledge  our  indebtedness  for  assistance  to  our  colleagues 

in  the  Augustana  Hospital  and  especially  to  Drs.  Frank  Smithies,  Ethan  Allen 

Gray  and  Henry  Schmitz  for  aid  in  their  specialties. 

A.  J.  O. 

N.  M.  P. 


PREFACE  TO  THE  THIRD  EDITION 

For  some  time  there  has  been  a  demand  for  a  third  edition  of  this  work 
but  until  the  present  it  has  been  impossible  for  us  to  give  the  necessary  atten- 
tion to  make  the  careful  revision  which  seemed  indicated.  During  the  interval 
since  the  publication  of  the  second  edition  we  have  collected  material  con- 
stantl}'  for  this  new  edition.  We  have  also  had  ample  opportunity  to  test  many 
of  the  newer  methods  and  to  confirm  many  of  the  old  ones  as  we  have  kept 
careful  records  of  more  than  fifteen  thousand  operations  performed  by  us  in 
this  period. 

Our  methods  have  been  adopted  from  many  surgeons  and  adapted  to  our 
conditions.  In  many  instances  these  surgeons  have  kindly  furnished  personal 
information  and  illustrations  for  which  we  wish  to  express  sincere  gratitude, 
as  also  for  the  inspiration  and  encouragement  experienced  through  contact 
with  rhese  enthusiastic  and  tireless  workers  in  the  field  of  surgery. 

A.  J.  0. 
N.  M.  P. 

PREFACE  TO  THE  SECOND  EDITION 

In  the  preparation  of  the  second  edition  the  same  general  plan  has  been 
followed  that  was  introduced  in  the  first. 

With  increased  experience  in  the  use  of  operations  which  had  not  been 
fully  tried,  it  has  been  possible  to  make  some  portions  of  the  text  more 
complete. 

The  additional  material  has,  however,  all  been  substantiated  by  my  own 
clinical  experience  and  can  be  depended  upon  in  the  same  manner  as  the  por- 
tion of  the  book  which  appeared  originally. 

In  the  chapter  on  stomach  surgery  an  article  b}^  Dr.  W.  Mayo  has  been 
introduced  in  full  because  this  covers  the  subject  so  perfectly  that  it  would  be 
impossible  to  improve  upon  it.  I  am  again  greatly  indebted  to  this  author  for 
many  valuable  suggestions  as  well  as  for  a  number  of  most  excellent  original 
plates. 

The  text  has  been  increased  by  about  sixty  pages,  and  the  number  of  plates 
has  been  increased  by  nearly  fifty  per  cent. 

The  views  expressed  concerning  the  treatment  of  certain  forms  of  appen- 
dicitis, which  differed  materially  from  the  generally  accepted  plan  at  the  time 
of  publication  of  the  first  edition,  has  been  tried  by  hundreds  of  surgeons  who 
have  been  able  to  follow  the  method  carefully  as  described  in  this  volume. 
Many  of  these  have  kindly  informed  me  of  the  success  they  have  obtained  in 
this  direction. 

My  own  experience  in  the  treatment  of  more  than  one  thousand  cases  of 
appendicitis  during  the  past  three  years  has  further  confirmed  the  correctness 
of  these  views. 

I  wish  to  express  my  thanks  to  the  many  surgeons  who  have  shown  their 
appreciation  of  my  efforts  in  the  production  of  the  first  edition. 

A.  J.  0. 
8 


PREFACE  TO  THE  FIRST  EDITION 

Many  practitioners  who  have  honored  the  author  by  visiting  his  clinic  have 
requested  that  a  work  on  Clinical  Surgery  be  written  by  him,  giving  as  nearly 
as  possible  the  methods  adopted  in  actual  practice.  This  request  has  been  met 
by  the  statement  that  the  author  lays  no  claim  to  the  invention  of  a  single  new 
operation,  nor  has  he  produced  a  new  or  modified  instrument,  but  has  con- 
tented himself  with  applying  to  his  surgical  work  what  seemed  best  in  the 
practice  of  the  surgeons  of  the  past  and  present,  many  times  without  knowing 
by  whom  the  various  methods  were  modified  before  they  were  accepted  and 
used  by  him. 

This  book  is  therefore  offered  for  what  it  is  worth  under  the  limitations 
mentioned,  the  author  being  conscious  of  a  certain  incompleteness  because  of 
adhering  closely  to  the  intention  of  producing  a  work  reflecting  almost  entirely 
the  methods  which  have  been  thoroughly  tried  in  his  own  practice. 

In  recommending  certain  steps  the  author  does  not  desire  to  impress  the 
fact  that  the  method  chosen  or  advised  is  the  best,  or  the  only  good  one, 
but  rather  that  it  stands  as  a  means  he  has  thoroughly  tried  and  which  can 
be  reasonably  relied  upon.  Whenever  there  is  any  doubt  upon  this  point  it 
is  expressly  so  stated  in  the  text. 

There  are  necessarily  some  branches  of  clinical  surgery  in  which  the 
author's  experience  is  limited,  and  it  has  seemed  best  to  indicate  this  in  the 
text  in  discussing  the  special  subjects  thus  impaired. 

Certain  operations  can  obviously  have  no  place  in  this  volume,  because 
they  have  been  described  in  a  given  way  by  many  writers  for  years,  and 
would  simply  consume  space  for  reiteration  without  increasing  the  value  of 
the  work.  I  refer  especially  to  the  typical  ligations,  amputations  and  the 
resections  of  joints. 

A  portion  of  this  work  deals  with  clinical  cases  taken  from  hospital  records 
and  discussed  as  one  discusses  such  cases  in  practice.  This  has  been  done 
for  the  purpose  of  bringing  the  actual  clinical  conditions  before  the  mind 
of  the  reader.  It  did  not  seem  wise  to  carry  this  plan  through  the  subjects  in 
which  it  was  possible  to  bring  out  the  salient  points  in  more  concentrated 
manner.  In  order  to  impress  the  reader  with  the  cardinal  facts  upon  which 
success  in  the  treatment  of  various  conditions  depends,  many  unimportant 

9 


10  PREFACE 

and  useless  matters  have  been  intentionally  omitted.  This  undoubtedly  re- 
duces the  scientific  merit  of  the  book,  but  it  has  appeared  to  the  author  to 
increase  its  practical  value. 

No  reference  is  made  to  authors  whose  methods  are  described,  because 
most  of  the  procedures  set  forth  were  not  used  in  their  original  form,  having 
been  repeatedly  modified,  usually  by  a  number  of  operators.  In  order  to 
give  each  one  the  due  amount  of  credit  deserved  the  work  would  have  grown 
far  beyond  the  designated  limits.  An  exception  is  made  in  those  cases  in 
which  the  original  drawings  of  writers  are  employed.  The  author  is  indebted 
to  all  of  his  friends  in  the  surgical  profession  whose  methods  he  has  adopted, 
and  hopes  that  where  they  find  familiar  details  they  will  appreciate  the 
gratitude  he  bears  toward  them  for  having  markedly  assisted  in  the  improve- 
ment of  his  technique. 

All  drawings  herein  are  original,  having  been  made  by  Miss  Alice  L.  Cleave- 
land  for  this  volume  from  immediate  operations,  with  the  exception  of  a  few 
which  were  taken  from  original  publications  of  other  authors;  the  latter  are 
especially  designated  in  their  accompanying  text. 

The  author  is  particularly  indebted  to  his  friend,  Dr.  W.  J.  Mayo,  for 
many  valuable  suggestions,  and  to  his  brother.  Dr.  E.  H.  Ochsner,  and  his 
chief  assistant,  Dr.  Nelson  M.  Percy,  for  relieving  him  of  many  burdens 
incident  to  the  production  of  a  book. 

Finally,  it  should  be  said  that  this  work  is  not  written  for  the   great 

surgeon,  or  the  teacher  of  surgery,  whose  methods  are  as  well  tried  as  those 

contained  in  this  volume,  and  undoubtedly  quite  as  useful,  but  rather  for 

the  man  who  is  compelled,  by  virtue  of  the  circumstances  surrounding  him, 

to  do  surgery,  and  who  wishes  to  know  what  the  author  would  do  in  a  similar 

case  to  the  one  he  happens  to  have  under  treatment  at  any  given  time.     He 

may  be  familiar  with  many  methods,  but  at  the  same  time  may  wish  to  know 

which  one  has  seemed  most  satisfactory  to  the  author. 

A.  J.  0. 


LIST  OF  ILLUSTRATIONS 

Page. 

Military   woiinds    Frontispiece 

Counting   erythrocytes    (2) 39 

Anterior  incisional  lines    75 

Anterior  abdominal  incisional  lines 76 

Posterior  incisional   lines    77 

Various  surgical  instruments   (32) 88-95 

DeVilbiss  forceps  and  proper  trephine 103 

Traumatic    epilepsy    109 

Diagrams  of  areas  of  cerebral  localization 110 

Hydrocephalus  ^vith  Jacksonian   epilepsy 112 

Hogluncl's  electric  rotary  chain  saw 113 

Cranial  areas  for  osteopathic  operations 116 

Temporary-  resection  of  the  skull 120 

Cleft  palate   operation 128 

Excision  of  the  tongue   142 

Epithelioma   of  the   cheek 147 

Epithelioma   of  the   cheek 148 

Carcinoma  of  the  lower  lip 148 

Adenoma  of  the  thyroid  gland  (2) 154 

Exophthalmic   goitre    (2) 157 

Adenoma  of  the  thyroid  gland 158 

The  thyroid  gland  and  its  relations ' 159 

Thyroidectomy 161 

Bovine  tuberculosis   of  the  neck ITO 

Sarcoma  of  the  neck  (2) 174 

Laryngectomy    (2)    177 

Ulcer  of  the  chest  wall 196 

Skin-grafts  protected  by  wire  netting 197 

Chronic  cystic  mastitis 205 

Amputation  of  breast 206 

Amputation  of  breast ;  outline   of  incision    207 

Amputation  of  breast;  exposure  and  divisions  of  the  peetoralis  major..  208 

Amputation  of  breast ;  isolation  of  the  peetoralis  major 209 

Amputation  of  breast ;  peetoralis  major  severed 210 

Amputation  of  breast ;  insertion  of  sutures    211 

Amputation  of  breast;  flap  sutured  and  drainage  tube  placed 211 

Amputation  of  breast   for   carcinoma 212,  213 

Cancer  en  cuirasse   214 

11 


12  LIST  OF  ILLUSTRATIONS 

Page. 

Scar  following  complete  mammectomy 215 

Recurrent  carcinoma  of  the  breast 216 

Rodman's  amputation  oi  the  breast 216 

Rodman's  amputation  of  the  breast  (2) 217 

Rodman's  amputation  of  the  breast   (2) 218 

Rodman's  amputation  of  the  breast   (2) 219 

Epithelioma  of  the  breast 219 

Lipoma  of  the  breast 220 

Chondrectomy  for  relief  of  bronchial  asthma 225 

Location  of   abdominal   incisions 229 

Excision  of   appendix    (3) 236 

Closure  of  McBurney's  incision 239,  244,  246 

McBurney's  incision  with  lateral  extension 251 

Constricted  appendix  (2)    263 

Adherent   appendix    266 

Glass  syringe  for  rectal  feeding ., 270 

Adherent   appendix    272 

Abdominal   incision    275 

Closure   of  McBurney  incision 277 

Intestinal  anastomosis 294 

Intestinal  anastomosis  with  Murphy  button 296 

Lateral   intestinal    anastomosis 298 

Murphy   button 299 

Intestinal  anastomosis,  end-to-end  with  sutures 300 

Connell  method  of  intestinal  suturing  (5) 302 

Council  method  of  intestinal  suturing  (4) 303 

End-to-end  anastomosis  of  colon 307,  308 

Inguinal   colostomy    310 

Operation  for  elimination  of  the  ascending,  transverse   and  descending 

colon 313 

Intestinal  x-ray    314,   315,   316 

Colon  resection  by  Lane  method  (3) 318 

Excision  of  cecum  and  ascending  colon 320 

Excision  of  cecum    321 

Carcinoma  of  the   cecum 323 

Intestinal  obstruction  due  to  spasmodic  contraction  of  ileum 329 

Bilateral  indirect  oblique  inguinal  hernia 335 

Indirect  oblique  inguinal  hernia 335 

Bassini's  operation  for  inguinal  hernia 336 

Ferguson's  operation  for  inguinal  hernia 338,  339,  340,  341 

Femoral  hernia 345 

Femoral  hernia ;    anatomical   relations 346 

Umbilical  hernia    349,   350 

Umbilical  hernia ;  Mayo's  operation  for 351 

McBurney 's   incision    354 


LIST  OF  ILLUSTRATIONS  13 

Page. 

Closure  of  abdominal  wound 355 

Abdominal  wall,  upper  three-fourths 356    357 

Abdominal  wall,  lower  one-fourth 358 

Closure   of   abdominal  wound 361 

Congenital  oblique  inguinal  hernia    (2) 365 

Indirect   oblique   inguinal   hernia 369 

Vessels  of  spleen  clamped  by  long  forceps 379 

Clamp  and  cautery  operation  for  hemorrhoids 394 

Rectal   fistula    398 

Elastic  esophageal  bougies  (4) 409 

Gastrostomy    (4)    412 

Dilatation  of  stricture  of  esophagus  (4) 421,  423 

Plummer's  whalebone  staff   429 

Typical  chronic  gastric  ulcer   (2) 433 

Stomach    tube    435 

Radiogram  of  stomach,  showing  carcinoma 439 

Radiogram  of  stomach,  showing  ulcer 440,  441,  442 

Glass   slide   specimens 446 

Radiogram  showing  dilated  stomach 447,  448 

Radiogram  showing  large  steer-horn  stomach 449 

Radiogram  showing  hour-glass   contraction   of  stomach 450 

Radiogram  showing  chronic  perforating  gastric  ulcer 455 

Radiogram  showing  patent  gastro-enterostomy  opening 456 

Radiogram  showing  perforating  gastric  ulcer 457 

Radiogram  showing  extensive   gastric   carcinoma 458 

Radiogram  showing  general  gastric  carcinoma 463 

Mayo-Moynihan  method  of  gastro-enterostomy.  . .  .465,  466,  468,  470,  471,  472 

Exclusion   of  pylorus    (3) 473 

Enterostomy  with  McGraw  ligature 476,  477,  478,  479 

Gastro-enterostomy  481,  483,  485 

Beck's   gastro-enterostomy   (2)    488 

Stomach  showing  distribution  of  lymph  nodes 490 

Carcinoma  of  pylorus -192,  493 

Pylorectomy  with  partial  gastrectomy 495,  496,  497 

Beyer's   operation   for   gastroptosis 499 

Diverticulum  of  the  gall  bladder 507 

Gall   bladder  removed 508 

Incisions  for  gall  bladdei  and  gall  duct  operations 515 

Some  instruments  used  in  gall  bladder  surgery  (5) 517 

Cholecystotomy 518 

Retention   tube    520 

Removal  of  stone  from  common  duct 521 

Excision  of  the  gall  bladder  (6) 523,  524,  526,  527 

Mayo  Robson's  position  of  the  patient 528 

Circular  muscle  fibres  of  the  duodenum 529 


14  LIST  OF  ILLUSTRATIONS 

Page. 

Resection  of  the  liver 533,  534 

Harris '  segregator    539 

Radiogram  of  renal  stone   541 

Radiogram  of  left  ureter :  .542,  543 

Atrophy  of  kidney  "with  large  cyst 546 

Hydronephrosis 552 

Nephrectomy   553,  554,   556 

Nephrorrhaphy 560 

Radiogram   of  renal   calculus 563 

Anastomosis  of  the  ureter 567 

Exstrophy  of  the  bladder 569,  570,  571,  572,  573 

Hypospadias  operation  (20) 575,  576,  577,  579,  580 

Varicocele  operation 584 

Hydrocele 58(5 

Hydrocele  of  the  cord  and  varicocele 587 

Encysted  hj'drocele  of  the  cord 588 

Wyllys  Andrews'  method  of  hydrocele  operation 589 

Prostatectomy 599 

Bilateral  papillo-cystadenoma  of  the  ovaries    610 

Abdominal  incision  through  linea  alba 612 

Abdominal  hysterectomy   616,  617,  618 

Radiograph    of   female   pelvis 620 

Irrigation  apparatus    (2)    624 

Vaginal  hysterectomy   629,  631,  632,  634 

Microscopical  section  from  cervix  uteri 635,  636,  637,  638 

Uterine   carcinoma    641 

Excision  of  elongated  cervix  uteri  (2) 643 

Closure  of  wound  in  cervix 644 

Amputation  of  lacerated  cervix  uteri 645,  646,  647 

Perineorrhaphy 649 

Excision  of  urethra    651 

Gillam  operation  for  cystocele 654,  655 

Radiograms  of  fracture  of  femur  and  humerus   (2) 662 

Radiograms  of  fracture  of  humerus  and  tibia   (2) 663 

Radiogram  of  ununited  fracture  of  ulna  and  radius 665 

Radiograms  of  fracture  of  the  femur  (2) 666 

Radiogram  of  fracture  of  neck  of  the  femur 668-669 

Radiogram  of  fracture  of  the  humerus 670,  671 

Radiograms  of  fracture  of  the  tibia  and  fibula  (2) 672 

Radiograms  of  fracture  of  the  tibia  (2) 673 

Radiograms  of  fracture  of  the  lower  third  of  femur  (3) 674 

Radiograms  of  fracture  of  femur   (2) 675 

Radiograms  of  fracture  of  the  patella  (2) 680 

Radiogram  of  fracture  of  the  patella 681 

Radiogram  of  fracture  of  outer  third  of  clavicle ." 683 


LIST  OF  ILLUSTRATIONS  15 

Page. 

Large,  moist  antiseptic  dressing  (2) 693 

Electric  light  bath,  apparatus  for  an  extremity 695 

Surgical  treatment  of  varicose  veins  (2) 698 

Varicose  ulcer   (3)    700 

Protecting  skin-grafts 702 

Operation  for  lengthening  contracted  tendons 706 

Excision  of  the  ankle 710 

Arthroplasty   for   intra-articular    ankylosis    of    the    temporo-mandibular 

articulation   (2)    716,   717 

Case  of  multiple  tumors  of  the  bones 722 

Osteoid  chondroma  of  the  humerus   (2) 723 

Elephantiasis  of  the  arm 727 

X-ray  pictures  of  amputation  stumps  (2; 728 

Mayo 's  operation  for  bunion    (3) 733 

Transfusion   apparatus    738 

^Multiple  wounds  caused  by  bomb  explosion 746 

Different  degrees  of  trench  foot  (2) 747 

TjT)es  of  shrapnel  in  modem  use 749 

Present-day   cartridges    (3) 750 

Actual  size   of  shrapnel  bullets 751 

Ground  plan  of  surgical  field  hospital 754 

Army  corps   surgical  unit 755 

Detail  of  surgical  field  hospital 756 

Perforating  wound  of  the  arm 761 

Gas  bacillus  infection 765 

Microscopical  appearance  of  gas  gangrene  in  muscle 766 

Flapless  amputation  (2) 767 

Flapless  amputation 768 

Shell  wound  of  the  lower  jaw 776 

Fragment  of  high  explosive  shell 776 

Shrapnel  wound  of  the  face  and  jaw  (3j 777 

Bullet  wound  of  the  spleen 783 

Bullet  woiuids  of  the  small  intestine 783 

Interrupted  plaster  cast  on  the  leg 785 

The  hinged  cradle  splint  (2) 785 

Blake 's  splint  applied  to  the  leg 785 

Location  of  hospital  buildings 788 

Plan  of  block  hospital 789 

Plan  of  a  general  hospital 791 

Plan  of  undesirable  arrangement  of  hospital 793 

A  gynecological  and  obstetrical  hospital 796 

Plan  of  a  U-shaped  hospital 798 

A  country  hospital 800 

Plan  of  a  small  general  hospital 802 


PART  I 

GENERAL  SURGICAL  CONSIDERATIONS 


EXAMINATION  OF  THE  PATIENT 

The  benefits  of  clinical  surgery  cannot  be  realized  to  the  fullest  extent 
without  considering  the  patient  himself,  aside  from  the  disease  for  the  cure 
of  which  he  seeks  surgical  treatment.  Much  of  the  surgeon's  success  depends 
upon  the  value  of  his  judgment  and  knowledge  outside  of  his  especial  line 
of  work.  Many  patients  may  live  in  relative  comfort  for  a  considerable  period 
of  time  whose  lives  otherwise  may  be  cut  short  by  an  attempt  to  obtain  com- 
plete relief.  On  the  other  hand,  many  patients  may,  with  the  same  degree  of 
safety,  obtain  complete,  rather  than  partial  relief,  as  a  result  of  the  excellence 
of  the  surgeon's  judgment. 

Clinical  experience  of  the  surgeon.  To  excel  to  the  fullest  extent,  the 
surgeon  requires  not  only  the  necessary  knowledge  to  make  the  proper  diag- 
nosis, and  technical  skill  to  perform  the  necessary  operation,  but  he  must 
also  have  an  extensive  clinical  experience  which  can  fortunately  be  obtained, 
in  this  country  at  least,  in  service  as  assistant  to  those  who  possess  this 
experience,  particularly  in  the  great  number  of  excellent  hospitals  which  have 
been  established  in  most  of  the  larger  cities. 

General  examination  of  the  patient.  In  order  to  be  able  to  judge  of  the 
patient's  condition,  aside  from  the  particular  ailment  from  which  he  is 
suffering,  it  is  necessary  in  each  case  to  make  a  careful  general  examination. 
This  should  include  a  physical  examination  of  the  head,  neck  and  chest,  the 
abdomen,  the  nervous  system ;  a  chemical  examination  of  the  urine,  and  at 
least  an  observation  of  the  character  of  the  fseces.  In  many  cases  the  blood 
should  be  examined,  and  if  there  is  cough  the  sputum  should  be  examined. 

Diagnostic  section  of  tumors  condemned.  In  making  an  examination  we 
should,  however,  be  exceedingly  careful  not  to  fall  into  the  opposite  error 
of  making  a  diagnosis  without  regard  to  the  patient.  We  have  repeatedly 
seen  patients  lose  their  lives  because  of  the  fact  that  the  surgeon  felt  it  his 
duty  to  make  a  positive  diagnosis.  This  is  especially  true  of  cases  in  which 
portions  of  safely-removable  tumors  were  excised,  previous  to  their  total 
removal,  for  microscopic  examination  for  the  purpose  of  making  a  positive 
diagnosis.  In  these  instances  we  have  frequently  seen  metastases  appear 
very  soon  after  this  apparently  unimportant  preliminary  diagnostic  operation 
was  performed,  which  were  probably  due  to  the  excision  of  the  small  por- 
tion. We  believe  this  should  be  very  strongly  condemned,  because  the  removal 
of  a  benign  tumor  is  in  reality  a  harmless  performance  compared  with  the 
dissemination  of  a  malignant  growth.  There  are  but  few  exceptions  to  this 
rule,  chiefly  in  bone  tumors  in  which  the  treatment  of  a  malignant  growth 
would  necessitate  an  amputation,  while  a  benign  tumor  can  safely  be  removed 
from  the  implicated  bone. 

Diagnostic  palpation  of  tumors  condemned.  In  connection  -with  the  diag- 
nosis of  malignant  tumors  we  would  also  caution,  veiy  emphatically,  against 

2 

17 


18  GENERAL  SUROICAL  CONSIDERATIONS 

applying  much  pressure  to  the  surfaces  of  these  growths.  AVe  have  observed 
many  a  case  of  carcinoma  of  the  breast,  for  instance,  which  had  remained 
almost  stationary  for  many  months  until  the  patient  began  to  have  it  exam- 
ined. Each  successive  examining  physician,  and  all  the  patient's  friends, 
had  thoroughl}^  massaged  the  growth  during  repeated  examinations  and  it 
seems  reasonable  to  suppose  that  in  this  way  the  rapid  increase  in  growth, 
the  involvement  of  the  lymphatic  glands,  and  possibly  the  metastasis  in  the 
liver  could  be  explained,  because  of  the  likelihood  of  forcing  cells  from  the 
primary  growth  into  the  lymph  channels. 

In  the  same  manner,  we  have  observed  that  patients  suffering  from  septic 
infections  of  the  extremities  regularly  show  a  rise  in  temperature  after  a 
thorough  examination,  during  which  every  effort  was  made  to  locate  points  of 
fluctuation. 

It  seems  reasonable,  therefore,  to  condemn  what  might  be  called  diagnostic 
massage,  at  least  in  all  patients  suffering  from  malignant  growths  and  septic 
infections. 

Exploring  syringe  condemned.  The  exploring  syringe  is  an  instrument 
which  is  also  responsible  for  much  harm,  because  in  many  cases  in  which 
pus  has  been  diagnosed  positively  without  this  instrument,  the  syringe,  instead 
of  confirming  the  diagnosis,  shows  negative  results,  on  account  of  some 
obstruction  in  the  lumen  of  the  exploring  cannula  used. 

In  a  number  of  instances  we  have  seen  great  accumulations  of  pus  removed 
from  empyemata  and  other  abscesses  after  repeated  tests  with  the  exploring 
syringe  had  resulted  negatively.  This  is  frequently  the  case,  even  when  a 
needle  with  large  caliber  is  used.  Many  an  abscess  has  remained  unopened 
because  the  exploring  needle  was  supposed  to  afford  a  positive  test. 

In  other  cases  extensive  and  serious  infections  have  been  caused  by  the 
use  of  the  exploring  syringe  because  the  great  pressure  under  which  the  pus 
was  confined  in  the  abscess  has  forced  it  into  the  surrounding  tissues  or 
cavities  along  the  puncture  made  by  the  exploring  needle.  ^ 

In  exploring  the  brain  for  the  location  of  an  abscess  it  is  sometimes  neces- 
sary to  use  an  exploring  s^'ringe  with  a  large  cannula — it  may  also  be  useful 
in  differentiating  between  pleurisy  with  effusion  and  empyema — but  aside 
from  this  we  believe  that  its  use  should  be  discarded. 

All  that  has  been  said  against  the  use  of  the  exploring  syringe  can  be 
uttered  with  much  greater  emphasis  against  an  instrument  which  has  fortu- 
nately been  almost  entirely  discarded,  namely,  the  grooved  exploring  needle. 
This  instrument  possesses  all  of  the  bad  qualities  of  the  exploring  syringe 
to  an  exaggerated  extent,  without  having  any  of  its  good  qualities. 

If  it  seems  advisable  to  make  use  of  an  exploring  syringe  in  a  given  case 
it  should  be  armed  with  a  trocar  of  the  desired  size  instead  of  the  ordinary 
aspirating  needle,  as  the  former  is  much  less  likely  to  be  obstructed  and  is 
therefore  more  certain  to  give  the  desired  information. 

The  personal  element  of  risk  in  operations.  In  considering  the  patient  in 
relation  to  the  advisability  of  an  operation,  it  will  be  found  that  in  a  large 
majority  of  cases  there  is  scarcely  any  doubt  regardin^g  his  ability  to  bear 
the  operation  itself,  barring  accidents ;  but  this  fact  should  not  lead  us  to 
take  for  granted  that  this  will  be  the  case  in  any  individual  case  without 
having  taken  pains  to  make  sure.  With  experience  one  learns  to  place  cer- 
tain cases  in  the  class  of  good  risks  and  others  in  the  class  of  bad  risks,  with 
many  intermediate  grades;  and  it  is  not  an  easy  matter  to  classify  these 
cases  so  that  one  who  has  not  actually  come  in  contact  with  them  can  appre- 
ciate their  difference  even  with  a  very  minute  description. 

We  would  class  among  the  good  risks  patients  who  are  nearly  normal 
as  regards  all  the  organs  of  the  body,  with  the  exception  of  the  part  involved 


GENERAL  SURGICAL  CONSIDERATIONS  19 

in  the  disease  for  which,  the  operation  is  to  be  performed;  if  the  disease  is 
not  located  within  or  near  an  important  organ ;  and  provided  that  the  opera- 
tion is  not  to  be  done  for  the  relief  of  a  disease  due  to  an  acute  infection. 
If  the  operation  is  to  be  performed  for  the  relief  of  an  acute  infection,  then 
the  risk  will  depend  upon  the  question, — Can  the  progress  of  this  infection 
surely  be  checked  by  the  operation? 

It  seems  that  an  acute  infection  does  not  respect  natural  strength  or 
endurance.  "We  have  here,  however,  quite  a  safe  guide  in  the  condition  of 
the  pulse.  An  operation  performed  upon  a  patient  with  a  pulse  of  over  120 
beats  per  minute  must  always  be  looked  upon  as  serious,  and  with  a  pulse 
still  higher  the  gravity  of  the  condition  increases  rapidly.  If  the  operation 
will  remove  the  existing  septic  material  and  at  the  same  time  make  a  further 
infection  impossible,  or  at  least  unlikely,  then  it  must  be  looked  upon  as  being 
relatively  safe. 

Old  age  of  itself  not  a  contraindication  to  surgical  operations.  Among 
the  conditions  almost  always  enumerated  as  contra-indicating  serious  opera- 
tions is  old  age.  There  are  certain  very  good  reasons  for  this.  A  person  who 
has  lived  many  years  has  had  relatively  more  opportunity  to  impair  his 
various  organs  than  one  who  has  lived  a  shorter  time.  Moreover,  his  tissues 
are  in  themselves  old,  and  especially  his  blood-vessels  have  lost  much  of 
their  elasticity.  On  the  other  hand,  we  must  bear  in  mind  that  the  fact  that 
these  persons  have  attained  great  age  would  indicate  that  they  were  pri- 
marily well  made,  or  that- their  normal  resources  have  been  well  preserved. 

As  a  matter, of  experience,  we  would  state  that  in  the  absence  of  obesity, 
myocarditis,  arterio-sclerosis,  nephritis,  marked  anemia,  or  cachexia,  due  to 
the  presence  of  malignant  growths,  patients  advanced  in  years  bear  surgical 
operations  well,  if  they  are  permitted  to  move  about  and  sit  up  soon  after 
the  operation.  (This  allowance  rarely  interferes  with  the  recovery  after  any 
operation,  provided  we  bear  this  in  mind  in  the  suturing  of  the  wound  and 
in  applying  the  dressings.) 

Confinement  to  be  avoided.  To  one  whose  attention  had  not  been  directed 
to  this  peculiarity  of  patients  advanced  in  years  it  might  seem  foolhardy  to 
permit  the  patient  to  sit  up  on  the  day  following  so  serious  an  operation  as 
a  herniotomy,  abdominal  section  or  an  amputation  of  the  breast  with  removal 
of  the  pectoralis  major  and  minor  muscles  and  the  axillary  fat  and  lymph 
glands,  but  experience  leads  us  to  say  that  in  operations  as  severe  even  as 
these,  the  course  mentioned  is  strongly  to  be  advised. 

Lowered  resistance  from  "high"  life.  There  is  one  element  which  it  is 
well  to  bear  in  mind  in  connection  with  the  consideration  of  old  age  in  surgery. 
Many  times  patients  not  much  over  forty  years  of  age,  whose  lives  since 
adolescence  have  been  spent  under  conditions  of  severe  mental  tension,  so 
common  among  business  and  professional  men  in  the  larger  centers  of  popula- 
tion at  the  present  time,  show  a  degree  of  senility,  so  far  as  their  nervous 
and  vascular  systems  are  concerned,  which  indicates  that  they  should  be 
classed  with  those  who  are  in  reality  from  twenty  to  thirty  years  older.  In 
these  patients  one  encounters  a  high  degree  of  arterial  tension,  an  erratic, 
nervous  heart,  and  there  is  usually  a  deficiency  in  the  excretion  of  urea. 
This  general  condition  is  much  more  common  among  men  than  among  women, 
because  men  are  more  constantly  exposed  to  nervous  and  mental  strain  than 
women,  with  the  possible  exception  of  the  small  and  useless  class  known 
as  "society"  women,  which  is  so  unimportant  as  not  to  require  attention 
save  to  point  the  contrast.  This  condition  of  instability  is  undoubtedly  exag- 
gerated by  the  poisonous  effects  of  nicotin  and  alcohol,  which  serve  so  well 


20  GENERAL  SURGICAL  CONSIDERATIONS 

as  temporary  stimulants  in  relieving  the  immediate  distress  of  mental  and 
nervous  strain  to  which  these  professional  and  business  men  are  exposed. 

In  these  cases  thorough  elimination  b}^  the  use  of  very  little  easily  digestible 
food,  the  taking  of  large  quantities  of  good  water,  the  gradual  reduction  in 
the  use  of  tobacco  and  abstinence  from  alcohol  are  strongly  indicated. 

Fresh  buttermilk  seems  to  be  especiall}'-  useful  both  as  a  food  and  as  an 
eliminant  in  these  cases.  Castor  oil  given  in  two-ounce  doses  in  the  foam 
of  beer  or  ale,  or  the  extract  of  malt,  aids  greatly  in  improving  the  condition 
of  this  class  of  patients.  The  use  of  continuous  proctoclysis  under  low  pres- 
sure or  by  the  drop  method  following  operation  is  especially  valuable  in  this 
class  because  by  favoring  elimination  proctoclysis  greatly  relieves  the  cir- 
culatory system. 

These  patients  should  never  be  exposed  to  long-continued  operations, 
and  they  are  especially  bad  subjects  for  nitrous-oxide-gas  anesthesia,  because 
of  its  effects  in  increasing  the  blood  pressure. 

Erratic  cases.  Many  cases  do  badly  after  operations  without  showing 
definite  symptoms  of  sepsis  or  complications  pointing  to  disease  of  the  kid- 
neys, heart  or  lungs,  although  all  of  these  organs  may  be  under  suspicion. 
There  may  be  too  small  an  amount  of  urine  secreted,  suggesting  the  likeli- 
hood of  acute  renal  congestion,  causing^  a  fear  of  impending  uremia,  or  the 
heart's  action  may  be  somewhat  erratic  or  weak,  causing  one  to  fear  that  a 
myocarditis  may  have  been  overlooked.  Again,  there  may  be  accelerated 
respiration  indicating  the  possibility  of  an  incipient  pneumonia,  or  these  con- 
ditions may  exist  simultaneously  with  or  without  beginning  sepsis. 

In  our  own  experience  it  has  seemed  as  though  one  can  usually  anticipate 
this  condition  by  a  careful  preliminary  examination,  together  with  a  careful 
consideration  of  the  patient's  historj^,  and  especially  that  part  of  the  history 
which  relates  to  the  habits  of  life,  particularly  as  regards  nervous  strain  and 
rest  and  the  use  of  alcohol,  tobacco  and  drugs ;  also  the  consideration  of  the 
quantity  and  quality  of  food  accustomed  to. 

On  the  other  hand  the  patient  can  often  be  protected  from  danger  by 
a  preliminary  course  of  hygienic  living,  especially  where  there  is  no  great 
urgency,  and  the  operation  is  for  chronic  conditions. 

Laxatives  before  operations.  We  have  used  various  forms  of  cathartics 
previous  to  operations  at  different  times,  but  have  now  come  to  depend  on 
but  one  cathartic  before  operation  in  all  cases  in  which  there  is  present  no 
form  of  peritonitis  or  intestinal  obstruction.  In  the  latter  classes  of  cases 
any  form  of  cathartics  or  laxatives  should  be  condemned  most  vigorously. 
In  all  others  two  ounces  of  castor  oil  are  given  to  adult  patients,  one-half 
this  dose  to  children  from  four  to  twelve  years  of  age,  and  proportionately 
less  to  youn^ger  children  and  infants. 

High  blood  pressure.  The  matter  of  abnormally  or  excessively  high  blood 
pressure  does  not  have  to  be  considered  in  patients  less  than  thirty-five 
years  of  age,  and  only  in  rare  instances  in  patients  less  than  fifty-five  years 
of  age.  It  should,  however,  be  borne  in  mind  that  it  is  in  fairly  young 
patients  that  one  is  most  likely  to  get  into  difficulties  from  this  cause,  because 
it  is  much  easier  to  overlook  this  source  of  danger  in  the  relatively  young 
patient  than  in  those  more  advanced  in  years. 

Operations  in  two  or  more  stages.  Many  of  these  patients  will  bear  an 
operation  which  involves  only  a  small  amount  of  trauma  without  any  diffi- 
culty, while  they  succumb  to  extensive  operations  in  which  they  are  subjected 
to  the  influence  of  anesthetics  for  a  considerable  period  of  time.  In  such 
cases  the  nervous  strain  accompanying  local  anesthesia  is  also  borne  very 
badly,  consequently,  there  is  not  much  choice  between  these  two  evils.    It  is. 


GENERAL  SURGICAL  CONSIDERATIONS  21 

however,  often  possible  to  perform  these  operations  in  two  or  more  stages. 
If  such  a  patient,  for  instance,  has  a  uterine  tumor  and  gall  stones,  or  a 
hernia  and  some  other  pathological  condition,  or  any  two  of  any  number 
of  other  combinations,  it  is  best  to  perform  one  of  these  operations  at  a  time. 
In  intracranial  affections,  for  instance,  it  is  better  to  make  a  temporary  skin 
and  bone  flap,  control  the  hemorrhage,  carefully  replace  the  flaps  and  com- 
plete the  operation  when  the  patient's  condition  has  been  thoroughly  restored. 

It  is  not  necessary  to  go  into  details  at  this  point,  the  general  principle 
involved  simply  contemplates  a  plan  by  which  as  small  a  burden  as  possible 
is  placed  upon  a  patient  who  is  not  in  a  good  condition  to  carry  additional 
burdens.  These  patients  usually  bear  repeated  light  burdens  better  than 
single  heavy  ones. 

Infants  bear  operations  weU.  The  same  seems  to  be  true  of  the  other 
extreme  in  age.  Infants  bear  operations  well,  provided  they  are  not  too  long 
continued,  nor  accompanied  by  too  great  loss  of  blood. 

Guard  against  hemorrhage.  The  mortality  in  infants  following  operations 
is  due  largely  to  shock  caused  by  the  trauma  of  the  operation  and  the 
hemorrhage.  It  is  important  to  remember  that  an  amount  of  trauma  which 
would  not  have  to  be  considered  in  adults  because  of  the  size  of  the  patient 
and  the  consistency  of  the  tissues,  may  result  in  serious  shock  in  infants 
and  young  children.  Again,  the  same  amount  of  blood  lost  by  a  child  weigh- 
ing fifteen  pounds  is  ten  times  as  serious  as  a  like  amount  lost  by  an  adult 
weighing  one  hundred  and  fifty  pounds. 

Operate  rapidly.  A  surgeon  who  is  slow  and  violent  in  his  manipulations 
should  therefore  choose  only  adult  patients.  Operations  upon  infants  should 
be  carefully  planned,  quickly  executed,  and  with  the  least  possible  amount 
of  trauma  and  the  smallest  possible  loss  of  blood. 

Quite  a  few  children  and  infants  die  after  operation  from  pneumonia. 
This  can,  however,  be  almost  completel}''  avoided  by  reducing  the  time  of 
operation  to  a  minimum,  by  permitting  the  child  to  almost  completely  come 
out  of  the  state  of  anesthesia  by  the  time  the  operation  is  finished,  and  by 
applying  the  sutures  so  that  the  patient  can  move  about  freely,  and  if  possible 
to  sit  up  in  bed,  soon  after  the  operation  has  been  terminated. 

Protection  of  the  mother  in  the  after-care  of  infants.  In  nurslings  it  is, 
moreover,  most  important  to  secure  the  co-operation  of  the  mother.  The 
latter  should  never  be  permitted  to  undertake  the  care  of  the  infant  after  a 
serious  operation,  because  the  resulting  fatigue  and  anxiety  will  surely  have 
a  harmful  effect  upon  the  milk,  and  the  child  will  consequently  suffer  from 
gastric  disturbances  in  addition  to  those  naturally  resulting  from  the  effects 
of  the  operation. 

These  conditions  should  be  carefully  explained  to  the  mother  so  that 
her  natural  anxiety  for  the  safety  of  her  child  will  serve  to  improve  its 
prognosis  rather  than  to  reduce  its  chances.  In  vaany  instances  we  have 
seen  a  worn-out  mother  improve  remarkably  in  health  during  the  time  her 
child  has  been  confined  to  the  hospital,  and  with  the  improvement  of  her 
general  condition  the  child's  nutrition  is  always  greatly  bettered.  The  mother 
should  not  live  in  the  hospital,  but  conveniently  near  so  that  she  can  come 
to  the  hospital  at  regular  intervals,  varying  from  three  to  four  hours,  accord- 
ing to  the  age  and  condition  of  the  child. 

It  is  well  for  the  mother  to  have  a  definite  program  which  she  must 
follow  absolutely.  She  should  never  be  permitted  to  carry  or  hold  the  child 
except  while  actually  nursing  it.  Before  she  nurses  the  child  the  first  time 
in  the  morning  she  should  drink  a  pint  of  hot  milk  or  gruel  so  that  she  will 


22  GENERAL  SURGICAL  CONSIDERATIONS 

not  be  in  a  depressed  state  during  the  act  of  nursing.  After  nursing  the 
child  she  may  take  a  walk  in  the  open  air,  then  breakfast  liberally,  then 
rest  for  at  least  one  hour  and  return  to  the  child  just  in  time  for  the  next 
feeding.  Her  luncheon  is  again  followed  by  a  period  of  rest.  In  the  middle 
of  the  afternoon  the  mother  may  take  some  nourishment,  preferably  a  pint 
of  milk,  with  bread.  She  may  take  a  liberal  meal  in  the  evening,  nursing 
the  child  at  regular  intervals  varjdng  from  two  to  four  hours  according  to 
the  requirements  of  the  little  patient,  the  time  of  nursing  being  so  arranged 
that  the  mother  can  obtain  from  seven  to  ten  hours  of  uninterrupted  sleep. 
She  should  always  take  some  nourishment  before  retiring.  Both  the  mother 
and  the  child  will  form  regular  habits  during  the  time  the  latter  is  in  the 
hospital  and  the  health  of  the  former,  and  the  nutrition  of  the  latter  invariably 
improve  to  a  marked  extent  under  these  circumstances. 

Importance  of  safeguarding  blood  supply.  For  all  patients  it  is  wise  to 
guard  against  the  loss  of  an  unnecessary  amount  of  blood ;  but  this  is  especially 
true  in  children  and  in  those  advanced  in  years,  because  many  of  these  do 
not  recover  readily  from  an  anemia  caused  by  a  great  exsanguination.  Every 
operation  should  be  carefully  planned  with  the  idea  of  preventing  the  unnec- 
essary loss  of  blood.  Usually  this  end  can  be  accomplished  if  the  surgeon 
lays  out  a  thoroughly  systematic  course  for  his  operation,  because  the  source 
of  hemorrhage  in  every  operation  can  be  anticipated  by  applying  two  pair 
of  forceps  to  each  one  of  the  larger  vessels  before  it  is  severed,  and  quickly 
applying  clamps  to  the  oozing  surfaces  as  the  operation  progresses,  in  all 
parts  of  the  body  in  which  it  is  not  possible  to  entirely  prevent  hemorrhage 
during  operation  by  the  application  of  elastic  constriction.  If  the  surgeon 
has  assistants  who  have  learned  how  to  concentrate  their  attention  during 
the  progress  of  the  work,  much  is  gained  in  saving  blood  because  tlie,y  will 
anticipate  the  surgeon  and  will  stop  all  hemorrhage  almost  instantl}"  at  those 
points  in  which  one  cannot  apply  forceps  before  se veering  the  tissues. 

Slow  vs.  rapid  operating.  There  are  two  errors  which  will  be  referred 
to  again  presently  which  the  surgeon  should  not  fall  into  in  his  attempts 
to  prevent  loss  of  blood,  namely:  too  rapid  and  too  slow  operating.  The 
former  is  certain  to  lead  to  calamity  occasionally  in  individual  cases,  although 
the  majority  of  patients  will  undoubtedlj^  do  well  under  very  rapid  technique. 
The  slow  operation  is  especially  likely  to  result  in  secondary  post-operative 
complications  such  as  pneumonia  and  nephritis. 

It  is  important  to  take  a  reasonable  attitude  regarding  this  feature.  It 
is  possible  to  be  guilty  of  insane  haste  on  one  side  and  of  imbecile  deliberation 
on  the  other, 

OBESITY 

Special  care  required.  Patients  who  are  very  obese,  especially  those  beyond 
middle  age,  require  particular  consideration.  Their  resistance  is  diminished ; 
they  recover  from  shock  less  speedily;  they  frequently  take  the  anesthetic 
badly;  and  they  are  more  liable  to  pneumonia  following  the  use  of  ether 
than  patients  with  a  normal  amount  of  fat.  Still  it  is  only  seldom  that  the 
presence  of  obesity  will  contra-indicate  an  operation  entirely.  Ordinarily 
it  would  simply  indicate  the  use  of  especial  care. 

In  many  of  these  patients  it  is  possible  to  reduce  the  weight  to  a  great 
extent  before  operation  by  following  a  s,ystematic  plan  of  dieting,  combined 
with  exercise  and  baths  to  be  described  presently. 


GENERAL  SURGICAL  CONSIDERATIONS  23 

In  planning  the  operation  in  these  cases  the  wound  should  be  so  sutured 
that  the  patient  can  move  about  freely  in  bed  and  if  possible  sit  up  directly 
afterwards,  especially  for  the  purpose  of  preventing  hypostatic  pulmonary 
congestion  following  operation.  In  most  of  these  cases  it  is  well  to  elevate 
the  head  of  the  bed  from  four  to  eighteen  inches. 

TUBERCULOSIS 

General  operations  inadvisable.  In  patients  suffering  from  tuberculosis 
an  operation  is  usually  borne  well  if  it  removes  the  tubercular  tissue.  If 
this  is  not  removed  by  the  operation  such  patients  frequently  do  not  do  well. 
Consequently  the  presence  of  tuberculosis  is  only  a  contra-indication  to  opera- 
tion in  a  limited  variety  of  cases.  In  patients  suffering  from  pulmonary 
tuberculosis  long-continued  operations  are  contra-indicated  chiefly  because 
the  disease  in  the  lungs  is  likely  to  make  progress  durin^g  the  time  that  the 
patient  is  recovering  from  the  depressing  effects  of  the  operation. 

It  is  difficult  to  say  whether  ether  anesthesia  is  really  in  itself  harmful 
in  these  cases.  It  has  been  suggested  that  anesthesia  by  inhalation  be  not 
employed  in  such  instances  and  that  local,  spinal  or  rectal  anesthesia  be 
substituted  in  all  cases  in  which  pulmonary  tuberculosis  is  present. 

Preliminary  general  treatment.  It  is  generally  possible  to  place  these 
patients  under  preliminary  hygienic,  dietetic  and  often  under  climatic  treat- 
ment for  the  cure  of  the  pulmonary  tuberculosis  before  they  are  subjected 
to  surgical  operations.  In  many  the  local  condition,  if  it  is  also  due  to  tuber- 
culosis without  mixed  infection,  will  recover  simultaneously  with  the  pulmo- 
nary tuberculosis.  This  is  true  especially  in  cases  suffering  from  joint 
tuberculosis  in  which  perfect  immobilization  has  been  accomplished  while  the 
pulmonary  condition  is  under  the  above  form  of  treatment. 

Surgical  relief  in  the  tuberculous.  Many  of  the  older  surgeons  have  noted 
the  fact  that  patients  suffering  simultaneously  from  a  mild  form  of  pulmonarj^ 
tuberculosis  improved  rapidly  after  operations  removing  extremities  contain- 
ing a  tuberculous  joint,  as  for  instance  an  amputation  of  the  hand  in  case  of 
tuberculosis  of  the  wrist,  or  amputation  through  the  lower  third  of  the  thigh 
in  case  of  tuberculosis  of  the  knee.  On  the  other  hand  they  found  that  similar 
cases  became  worse  rapidly  and  resulted  fatally  in  a  short  time  in  those  in 
which  an  attempt  at  excision  of  the  joint  was  practised.  Later  on  when  these 
latter  operations  were  performed  under  antiseptic  precautions  if  they  healed 
primarily  the  pulmonary  condition  usually  improved  rapidly,  while  if  they 
suppurated  the  opposite  was  true. 

Dr.  Emil  Beck  has  given  a  very  ingenious  explanation  for  these  facts. 
He  supposed  that  in  every  patient  suffering  from  tuberculosis  there  is  an 
attempt  by  nature  to  provide  a  sufficient  amount  of  antitoxin,  that  the  tuber- 
culosis tissue  removed  by  amputation  leaves  more  of  the  substance  in  the 
blood  to  combat  the  disease  in  the  lungs  and  elsewhere,  and  that  for  this 
reason  healing  occurs.  On  the  other  hand  if  the  organism  is  burdened  by 
any  additional  task,  as  for  instance  the  combating  of  a  mixed  infection,  the 
balance  changes  in  favor  of  the  disease  and  the  patient  succumbs  to  pulmo- 
nary tuberculosis.  The  shock  of  a  long-continued  bloody  operation  would 
undoubtedly  have  the  same  effect, 

CACHEXIA  DUE  TO  MALIGNANT  GROWTHS 

A  contraindication.  Ordinarily  the  presence  of  cachexia  in  patients  suf- 
fering from  malignant  growths  is  a  distinct  contra-indication  to  operation, 
because  these  patients  do  not  bear  operations  well  and  with  few  exceptions 


24  GENERAL  SURGICAL  CONSIDERATIONS 

derive  very  little  benefit  therefrom.  This  is,  however,  not  the  case  in  ulcerat- 
ing carcinoma  in  which  the  cachexia  is  due  largely  to  the  absorption  of  prod- 
ucts of  decomposition,  which  can  often  be  safely  eliminated  by  an  operation. 

Again,  in  cases  in  which  the  malignant  growth  interferes  with  nutrition 
by  obstructing  some  portion  of  the  alimentary  canal  this  rule  does  not  always 
hold  good,  because  frequently  the  improved  nutrition  greatly  overbalances 
the  traumatism  resulting  from  the  operation. 

In  a  general  way  it  may  be  stated  that  so  long  as  the  condition  in  a  given 
case  seems  to  indicate  the  possibility  of  removal  of  all  of  the  malignant  tissue 
the  operation  is  warranted  provided  it  does  not  necessitate  the  removal  of  a 
part  of  the  body  which  is  necessary  for  the  continuance  of  life.  In  some 
cases  the  apparent  cachexia  can  be  removed  before  operation  by  appropriate 
treatment. 

Example:  gastric  carcinoma.  In  cases  of  carcinoma  of  the  stomach,  for 
instance,  the  patient  frequently  absorbs  a  quantity  of  decomposing  substance 
during  a  considerable  period  of  time,  and  as  a  result  of  this  his  condition 
becomes  markedly  cachectic.  In  many  such  the  tumor  may  still  be  confined 
to  the  stomach.  If  operated  at  once  the  resistance  of  the  patient  may  be  so 
low  on  account  of  the  condition  described  above  that  he  may  succumb  to  the 
shock  of  the  operation.  If  the  same  patient  has  gastric  lavage  performed 
three  times  daily  at  intervals  of  eight  hours,  or  four  times  daily  at  intervals 
of  six  hours,  two  hours  after  receiving  some  concentrated  sterile  food,  his 
condition  will  improve  to  a  surprising  extent  in  from  one  to  two  weeks. 

The  ingestion  of  small  doses  of  oil  of  eucalyptus,  from  five  to  twenty 
drops  after  each  gastric  lavage,  is  of  further  aid  in  the  disinfection  of  the 
stomach  cavity.  In  the  meantime  the  patient's  strength  can  be  further  sup- 
ported by  giving  rectal  feeding  in  the  form  of  one  ounce  of  some  one  of  the 
various  concentrated  liquid  predigested  foods  in  the  market  dissolved  in  three 
ounces  of  normal  salt  solution,  administered  slowly  as  an  enema  through  a 
small  rubber  catheter  introduced  into  the  rectum  for  a  distance  of  not  more 
than  three  inches. 

One  danger  in  preliminary  treatment.  One  danger  must  be  borne  in  mind 
in  connection  with  this  form  of  preliminary  treatment.  In  many  instances 
the  general  welfare  improves  to  so  marked  an  extent  that  some  doubt  may 
arise  concerning  the  original  diagnosis,  and  this  ma}^  occasion  postponement 
of  the  operation  until  the  carcinoma  has  advanced  to  a  hopeless  point.  It  is 
always  bad  practice  to  postpone  operations  of  any  kind  in  patients  sufi:'ering 
from  malignant  growths,  because  after  such  a  growth  has  once  begun  to 
invade  the  surrounding  tissues  there  is  no  stopping  of  its  progress  except  by 
its  complete  removal  or  by  the  death  of  the  patient,  hence  the  importance 
of  not  losing  valuable  time  before  an  attempt  is  made  to  remove  the  growth. 

Durin,g  the  time  that  the  patient  is  under  observation  prior  to  operation 
it  is  well  to  administer  from  500  to  1,000  cc.  of  normal  salt  solution,  by  means 
of  Murphy's  proctoclysis,  from  four  to  six  times  each  day.  It  is  well  to  add 
to  each  application  from  30  to  60  cc.  of  one  of  the  various  recognized  concen- 
trated liquid  foods.  The  use  of  this  proctoclysis  has  a  tendency  to  fill  the 
blood  vessels  and  to  greatly  improve  the  resistance  of  the  parts. 

Blood  transfusion  may  be  emploj^ed  previous  to  operation  in  these  cases. 
It  is  often  of  great  value  in  preparing  cachectic  and  anemic  patients  for  opera- 
tion.   The  technique  is  described  elsewhere. 

SPEEDINESS  IN  OPERATING 

Two  viewpoints.  The  question  of  time  is  of  sufficient  importance  to 
demand  some  consideration.  It  is  only  necessary  to  look  upon  an  operation 
from  the  two  sides  which  have  a  bearing  in  order  to  come  to  a  proper  esti- 


GENERAL  SURGICAL  CONSIDERATIONS  25 

mation  of  the  importance  of  this  element :  1,  from  the  merely  mechanical 
or  technical  point  of  view,  and,  2,  from  the  point  of  applying  this  to  the 
patient. 

From  the  technical  standpoint  it  is  plain  that  a  skilled  mechanic  not  only 
does  his  work  well,  but  accomplishes  it  in  a  relatively  short  time,  while  one 
unskilled  will  have  much  less  satisfactory  results  by  taking  a  much  longer 
time ;  skill,  accuracy  and  facility  naturally  going  hand  in  hand  in  bringing 
about  the  highest  possible  outcome. 

Careful  haste.  However,  a  hasty  mechanic  may  complete  a  badly-con- 
structed product  in  a  relatively  short  period  of  time ;  and  it  is  consequently 
necessary,  from  a  purely  technical  standpoint,  to  distinguish  clearly  between 
speed  which  is  the  result  of  skill  and  dexterity,  and  speed  resulting  from 
carelessness,  wanton  haste  and  lack  of  thoroughness.  From  a  strictly  technical 
standpoint,  then,  we  have  a  right  to  demand  the  greatest  speed  compatible 
with  careful,  thorough  work.  When  we  come  to  apply  this  directly  to  the 
patient  still  further  elements  will  be  introduced. 

Hasty  and  careless  work  is  more  harmful  because  of  the  needless  trauma- 
tism which  it  is  likely  to  produce,  and  this  may  in  turn  result  in  shock  or 
in  the  injury  of  structures  needlessly  implicated.  The  patient  may  not  receive 
the  full  amount  of  benefit  through  lack  of  thoroughness,  some  conditions 
being  overlooked  and  neglected  on  account  of  undue  haste. 

Dangers  of  slowness.  On  the  other  hand,  it  is  almost  equally  bad  to  pro- 
long an  operation  needlessly,  because  this  exposes  the  patient  to  a  number 
of  unnecessary  dangers :  1,  A  prolonged  anesthesia  increases  the  danger 
immediately,  and  many  times  the  patients  will  recover  from  a  short  anesthesia 
with  scarcely  any  discomfort,  while  they  will  suffer  greatly  from  nausea 
and  vomiting  after  a  prolonged  anesthesia.  If  ether  is  employed,  a  pro- 
longed anesthesia  is  much  more  likely  to  be  followed  by  bronchitis  or  pneu- 
monia than  a  short  one.  2,  Other  things  being  equal,  the  amount  of  shock 
is  proportionate  to  the  relative  time  consumed  in  the  operation.  3,  Infection 
is  more  likely  to  occur  in  a  wound  which  has  been  exposed  to  manipulations 
for  a  long  time. 

Local  anesthesia  favors  deliberateness.  In  operations  performed  under 
local  or  spinal  anesthesia  the  element  of  time  is  of  course  very  much  less 
important  than  with  general  anesthesia,  provided  the  operation  is  completed 
before  tlie  local  anesthetic  has  lost  its  effect,  because  the  condition  of  the 
nerves  in  the  field  of  operation  prevents  shock  from  long  continued  manipu- 
lations and  there  is  no  danger  from  postoperative  pneumonia  unless  the 
patient  has  been  unnecessarily  exposed  to  cold  or  moisture.  Of  course,  if  the 
patient  has  been  chilled  during  the  operation,  this  may  give  rise  to  shock 
and  pneumonia  may  occur. 

Reasonable  speed  in  operating.  Then  again,  there  are  many  cases  in  which 
the  element  of  time  is  of  no  real  importance  because  the  procedures  are  so 
simple,  and  some  patients  are  so  vigorous  that  they  will  recover  even  if  they 
are  not  given  the  best  possible  conditions.  It  seems,  however,  reasonable 
to  demand  of  the  surgeon  a  fair  amount  of  technical  skill  and  dexterity, 
especially  as  there  are.  instances  in  which  the  lack  of  these  might  cause  the 
death  of  the  patient.  It  seems  foolish  to  hurry,  and  equally  so  to  prolong 
an  operation  unnecessarily. 

There  are  two  tendencies  which  become  quite  prominent  in  some  hos- 
pitals and  clinics  which  we  believe  should  be  abandoned,  one  of  these  might 
be  characterized  as  insane  haste  in  performing  operations  and  the  other  as 
imbecile  deliberation.  It  is  difficult  to  say  which  of  these  is  the  more  repre- 
hensible. 


26  GENERAL  SURGICAL  CONSIDERATIONS 

Of  course,  it  is  not  possible  for  all  surgeons  to  work  at  a  given  rate  of 
speed,  but  every  surgeon  should  strive  to  waste  no  time  and  without  hurry 
to  complete  each  operation  in  the  shortest  period  compatible  with  thorough- 
ness. Both  careless  handling  of  tissues  in  order  to  gain  speed  and  useless 
manipulation  while  wasting  time  should  be  avoided. 

In  extreme  cases  where  the  time  element  is  of  paramount  importance 
considerable  time  may  be  saved,  in  abdominal  cases,  by  closiu,g  the  wound  with 
silkworm-gut  sutures  through  all  the  layers,  and  placed  at  least  as  close  as 
11/2  cm.  apart. 

TRAUMATISM 

Importance  of  reducing  injury.  There  can  be  no  doubt  of  the  importance 
to  the  patient  of  reducing  the  traumatism  incident  to  surgical  operations 
to  a  minimum.  Even  though  the  patient  be  asleep,  and  consequenth^  not 
conscious  of  the  traumatism,  the  amount  of  injurj-  done  to  his  tissues  is 
a  definite  burden  placed  upon  him,  and  the  less  this  burden  is  the  better  for 
the  patient.  In  order  to  obtain  this  minimum  of  traumatism  the  conditions 
in  each  case  must  be  studied  separately  and  the  operation  planned  accord- 
ingly. It  is  often  possible  to  accomplish  the  same  result  through  a  small 
rather  than  through  a  large  incision,  which  will  reduce  the  amount  of  trau- 
matism ;  in  other  cases  it  would  require  much  crushing  of  the  tissues  in  a 
small  wound  while  the  same  operation  could  be  accomplished  through  a  large 
wound  without  this  added  injury. 

Above  all  things  a  surgeon  should  form  the  habit  never  to  manipulate 
tissues  needlessly  and  especially  not  to  manipulate  organs  which  are  not 
involved  and  which  may  readily  be  left  untouched. 

The  typical  operation.  In  many  instances  much  traumatism  is  caused 
by  the  surgeon  for  the  purpose  of  securing  an  absolute  repair  of  a  given 
lesion,  which  if  left  to  itself  would  heal  spontaneously  with  a  better  result 
and  at  less  expense  to  the  powers  of  the  patient.  This  is  true  especially  of 
the  newer  operations,  which  are  usually  quite  complicated.  One  by  one  the 
useless  elements  of  such  an  operation  are  eliminated,  and  with  this  progress 
much  of  the  traumatism  is  discarded.  And  this  statement  is  also  true  not 
only  of  the  individual  surgeon  who  naturally  accomplishes  any  given  opera- 
tion with  less  traumatism  after  he  has  performed  it  repeatedly,  than  during 
his  first  attempts,  but  there  is  always  developed  in  time  what  might  be  termed 
a  fairly  normal  or  typical  operation  from  which  experience  eliminates  most 
of  the  useless  and  practically  all  of  the  harmful  features.  Those  who  have 
been  actively  engaged  in  surgical  work  from  the  beginning  of  the  antiseptic 
era  to  the  present  time  have  had  an  excellent  opportunity  to  observe  this 
process  of  evolution  in  surgical  technique  in  connection  with  most  of  the 
operations  which  have  attained  an  established  position  in  the  field  of  clinical 
surgery. 

In  a  general  way  it  seems  proper  to  state  axiomatically  that  violent  sur- 
gery is  bad  surgery. 

Standardized  efficiency.  At  the  present  time  all  productive  manual  work 
in  the  various  manufacturing  industries  is  subjected  to  careful  study  by 
experts  for  the  purpose  of  determining  the  highest  possible  degree  of  effi- 
ciency. This  is  accomplished  by  systematic  motion  study  by  means  of  which 
it  is  possible  to  eliminate  unnecessary  motions.  This  plan  has  been  applied 
to  a  slight  extent  to  surgical  work  with  the  result  that  it  has  been  shown 
that  the  practical  surgeon  stands  at  the  bottom  of  the  scale  of  skilled  work- 
men. It  is  clear  that  it  is  our  duty  to  correct  this  defect  because  in  this 
way  the  margin  of  safety  can  be   enormously  widened  in  serious  surgical 


GENERAL  SURGICAL  CONSIDERATIONS  27 

cases  and  the  comfort  can  be  correspondingly  increased  in  those  that  are 
less  serious  but  equally  difficult.  Both  teachers  and  practitioners  of  surgery 
should  give  this  feature  the  study  and  attention  it  deserves.  In  the  manu- 
facturing industries  it  has  been  shown  that  by  this  study  the  poor  or  indif- 
ferent workman  can  in  this  way  much  more  easily  approach  the  efficiency 
of  the  really  excellent  workman  and  there  is  no  reason  why  the  same  results 
should  not  be  obtained  in  surgery. 

HEMORRHAGE 

Apply  hemostasis  at  once.  Except  in  especially  anemic  patients  a  mod- 
erate amount  of  blood  can  be  lost  durin^g  an  operation  without  causing  appre- 
ciable harm,  but  it  is  well  to  limit  the  amount  by  quickly  applying  hemostatic 
forceps  to  all  bleeding  points  the  moment  the  incision  is  made,  and  to  grasp 
the  larger  vessels,  whenever  possible,  between  two  pairs  of  forceps  before 
they  are  severed;  in  all  operations  upon  the  extremities  to  elevate  the  latter 
for  several  minutes  and  then  to  constrict  them  above  the  area  of  operation 
with  a  large  rubber  tube  or  a  broad  rubber  band  drawn  about  the  part  a 
number  of  times  and  tied.  If  the  extremities  are  constricted  in  a  careless 
manner  severe  harm  may  be  done  especially  to  the  nerve  trunks.  It  is  wise 
always  to  surround  the  part  with  a  towel  folded  upon  itself  about  four  times 
and  then  to  use  a  soft  rubber  drainage  tube  at  least  one  inch  in  diameter  as 
a  constrictor. 

The  pneumatic  constrictor.  Recently  a  number  of  contrivances  have  been 
introduced  which  are  intended  to  accomplish  complete  constriction  of  the 
blood  vessels  without  endangering  the  nerves.  One  of  the  best  of  these  con- 
sists of  an  adjustable  pneumatic  tube  which  is  applied  about  the  extremity 
at  the  desired  point  and  adjusted.  It  is  then  inflated  with  air  to  the  degree 
necessary  to  completely  obstruct  the  flow  of  blood  both  in  the  arteries  and 
veins.  The  same  apparatus  can  be  utilized  in  the  application  of  Bier's  local 
congestion  treatment  to  be  discussed  later.  It  is  plain  that  no  harm  can 
be  done  to  the  nerves  in  an  extremity  exposed  to  the  pressure  from  such  a 
pneumatic  constrictor. 

Hemostatic  forceps  and  clamps.  It  is  usually  not  difficult  to  reduce  the 
loss  of  blood  to  a  very  small  amount  without  consuming  a  great  deal  of 
time.  If  strong  hemostatic  forceps  are  used  the  ends  of  the  blood  vessels 
will  be  crushed  sufficiently  to  make  a  ligation  of  all  the  smaller  vessels  unnec- 
essary. It  is  well  to  leave  the  forceps  in  place  until  the  operation  has  been 
completed,  then  to  ligate  the  larger  vessels  and  simply  to  remove  the  forceps 
from  the  smaller  ones. 

Various  hemostatic  clamps  have  been  invented  for  the  purpose  of  con- 
trolling the  hemorrhage  during  and  after  operation  without  the  use  of  liga- 
tures, and  it  is  well  to  bear  this  feature  in  mind  in  purchasing  such  clamps, 
because  the  use  of  effective  instruments  of  this  kind  will  reduce  the  time 
of  operation  quite  sufficiently  to  merit  attention. 

Ligatures  preferable  to  torsion  or  crushing.  A  number  of  years  ago  the 
use  of  these  clamps  seemed  especially  indicated  because  ligature  material 
was  not  generally  reliable.  This  is  no  longer  the  case  as  catgut  can  now 
be  easily  prepared  according  to  methods  to  be  described  later  so  that  it  is 
absolutely  safe.  For  this  reason  it  seems  unnecessary  at  the  present  time  to 
make  use  of  torsion  or  crushing  in  dealing  with  the  larger  blood  vessels.  In 
the  largest  ones  like  the  femoral  or  axillary,  it  is  best  to  apply  two  catgut 
ligatures  from  two  to  five  mm.  apart. 

Hemophilia.  In  instances  of  hemophilia,  operations  should  always  be 
avoided  if  at  all  possible.     If  it  is  apparent  that   at  some  future  time  an 


28  GENERAL  SURGICAL  CONSIDERATIONS 

operation  will  become  necessary  it  may  be  well  to  make  use  of  preliminary 
treatment.  In  several  cases  we  have  found  benefit  from  givinc^  these  patients 
egg-albumin  in  considerable  quantities,  using  the  whites  of  three  to  six  eggs 
raw,  night  and  morning  for  a  number  of  months.  The  administration  of 
200  grams  of  ten  per  cent,  solution  of  gelatine  internally  every  day  for  a 
period  of  six  months,  has  been  found  beneficial  in  these  cases.  These  sub- 
stances can  be  disguised  in  various  ways  to  secure  palatabilit}-. 

Pre-operative  milk  diet  favors  hemostasis.  It  has  also  been  shown  experi- 
mentally that  the  amount  of  bleeding  is  much  less  in  patients  who  have  had 
a  liberal  milk  diet  for  several  weeks  previous  to  operation,  consequently 
Avhere  hemorrhage  is  feared  it  is  well  to  place  the  patient  on  a  full  diet  of 
milk  and  egg-albumin,  and  only  enough  other  food  to  keep  the  appetite  stimu- 
lated. 

Other  remedies  to  reduce  hemorrhage.  Several  remedies  have  been  much 
used  prophylactically  to  reduce  hemorrhage.  Of  these  chloride  of  calcium 
has  received  the  greatest  amount  of  prominence  since  its  introduction  by 
Mayo  Robson,  especially  in  the  sur.gery  of  the  biliary  tract.  Robson  employs 
this  remedy  both  before  and  after  operation,  giving  thirty  grains  in  half  a 
pint  of  water  three  to  six  times  daily  by  mouth  for  two  or  three  days  before 
the  operation,  and  sixty  grains  in  a  pint  of  warm  water  by  rectum  thrice 
daily  after  the  operation  for  two  or  three  days,  or  longer.  We  have  used 
this  remedy  in  many  cases  but  not  with  as  satisfactory  results  as-  anticipated. 

Ten-grain  doses  of  gallic  acid  given  everj-  two  hours  in  gelatin  capsules 
for  from  one  day  to  one  week,  in  cases  in  which  it  has  seemed  desirable  to 
reduce  the  amount  of  hemorrhage,  have  seemed  to  lower  the  amount  of  blood- 
lost  during  operation  to  a  very  marked  extent.  "Where  it  does  not  seem  wise 
to  postpone  the  operation  for  more  than  a  few  hours,  we  have  given  ten-grain 
doses  of  gallic  acid  hourly  for  a  period  of  from  ten  to  fifteen  hours  with- 
out having  observed  any  harmful  effect  from  the  relatively  large  amount  of 
the  drug  in  a  short  period  of  time,  while  it  has  seemed  that  the  effect  in 
reducing  the  hemorrhage  has  been  quite  marked  even  under  these  conditions. 

We  have  repeatedly  made  a  subcutaneous  or  intravenous  injection  of 
horse  serum  with  the  hope  of  increasing  the  coagulability  of  the  blood,  as 
suggested  by  many  authors.  It  has  seemed  to  benefit  these  patients,  but 
so  frequently  the  hemorrhages  stop  without  any  apparent  cause  that  there 
is  a  possibility  that  the  improvement  has  been  a  coincidence  in  our  cases 
although  we  have  not  thought  so.  Coagulose,  a  recent  preparation  of  the 
essential  blood  coagulating  ferment,  appears  to  have  but  little  merit  as  a 
hemostatic. 

In  a  number  of  cases  we  have  obtained  splendid  results  in  reducing  the 
tendency  toward  hemorrhage  by  transfusing  the  patient  with  blood.  The  blood 
thus  given  seems  to  furnish  elements  necessary  for  clotting  which  are  lacking 
in  the  patient.  The  reduction  in  coagulation  time  is  not  necessarily  perma- 
nent, but  will  serve  to  tide  over  the  time  of  operation.  The  method  of  trans- 
fusing will  be  found  described  elsewhere. 

Determination  of  coagulation  time.  When  there  is  reason  for  suspecting  a 
hemorrhagic  tendency  (as  in  cases  with  icterus,  leukemia,  etc.),  it  is  well  to 
determine  the  time  of  coagulation  of  the  blood  previous  to  operating.  This 
time  is  estimated  by  drawing  blood  from  a  needle  wound  into  a  small  bored 
glass  tube  (about  1  mm.)  up  to  a  standard  mark,  and  then  at  minute  intervals 
blowing  gently  through  the  other  end  of  the  tube.  As  long  as  the  blood  is 
fluid  it  will  leave  the  bore  and  form  a  drop  at  the  end  of  the  tube.  The  drop 
is  easily  drawn  back  into  the  tube.  When  the  blood  is  clotted,  it  either  remains 
lodged,  or  emerges  as  a  plug. 


GENERAL  SUEGICAL  CONSIDERATIONS  29 

The  tube  can  be  standardized  by  determinmg  the  coagulation  time  of  the 
blood  of  several  normal  individuals. 

ENVIRONMENT 

Temperature  of  the  operating  room.  The  atmosphere  in  an  operating 
room  should  be  between  68  and  72  degrees  F.,  because  such  a  temperature 
is  about  the  average  for  dwellings  in  this  coiintrv,  and  the  air  heated  to 
this  point  is  comfortable  both  to  the  patient  and  the  operator.  If  lower  it  is 
likelv  to  be  cooler  than  the  patient  is  accu>stomed  to  breathe:  if  warmer, 
it  is  likely  to  be  oppressive  to  the  operator  and  he  can  scarcely  be  expected 
to  do  his  best  work  when  he  is  practically  smothered  by  hot  air.  The  patient's 
body  should  be  protected,  except  at  the  field  of  operation,  and  this  need  not 
be  so  large  as  to  cause  chill.  It  is  well  to  place  hot  water-bags  about  a  patient 
on  the  operating  table  if  the  operation  is  expected  to  be  of  long  duration. 

Warm  operating'  tables.  Operating  tables  have  been  constructed  with 
double  tops  which  can  be  filled  with  water  heated  to  120  degrees  F.,  and 
which  will  remain  warm  throughout  the  operation,  or  which  can  be  kept  at 
a  given  temperature  by  the  use  of  an  electric  heater. 

Another  useful  contrivance  has  been  invented  in  the  form  of  a  fiat  rubber 
mattress  which  fits  upon  the  top  of  the  operating  table  and  which  is  filled, 
before  the  patient  is  placed  upon  it,  with  water  heated  to  120  degrees  F. 
This  is  exceedingly  simple  and  very  satisfactory. 

Another  plan  consists  in  a  row  of  incandescent  electric  lights  underneath 
the  table  which,  when  lighted,  will  supply  the  proper  amount  of  heat. 

"With  an  operation  of  less  than  one  hour's  duration  none  of  these  expe- 
dients is  necessary,  and  if  employed  in  cases  of  longer  duration,  the  simpler 
the  method  the  more  useful  it  is  in  practice. 

Influences  affecting  shock.  It  was  thought  at  one  time  that  shock  was 
caused  in  abdominal  operations  by  the  exposure  of  the  intestines  to  a  tempera- 
ture so  much  below  that  of  the  body,  but  this  theory  is  no  longer  tenable, 
because  no  abdominal  operator  exposes  the  intestines  to  the  atmosphere.  The 
shock  referred  to  above  was  undoubtedly  due  to  the  extensive  manipulations 
of  intra-abdominal  organs  practised  at  that  time. 

If  all  of  the  safeguarding  conditions  are  properly  considered  as  a  matter 
of  habit  in  connection  with  surgical  work,  and  all  means  of  correction  fol- 
lowed, it  will  be  found  that  the  post-operative  disturbances,  especially  those 
due  to  shock,  will  be  very  greatly  decreased. 

There  is  a  decided  difference  in  the  amount  of  shock  from  which  patients 
suffer  after  similar  operations  performed  by  different  surgeons,  and  we 
believe  that  this  difference  is  due  largely  to  the  fact  that  some  surgeons 
habitually  apply  all  of  the  principles  involved  in  the  above  considerations 
which  bear  upon  the  limitation  of  shock,  while  others  as  habitually  disregard 
them. 

It  is  also  well  to  bear  in  mind  the  fact  that  there  is  much  less  likelihood 
of  exposure  of  intestines  to  the  air  when  they  are  empty,  and  consequently 
in  a  thoroughly  collapsed  condition,  at  the  time  of  the  operation  than  if  they 
are  distended  with  gas  to  a  varying  degree.  In  all  cases  in  which  it  is  possible 
to  make  preliminary  preparation  this  condition  may  be  attained  by  giving 
the  patient  two  ounces  of  castor  oil  the  day  before  the  operation,  and  then 
giving  him  nothing  to  eat  except  broth  for  twenty-four  hours  previous  to 
the  operation. 

Mental  impressions  and  premonitions.  "We  have  adopted  the  rule  never  to 
operate  in  case  a  patient  is  afraid  or  has  a  premonition.  In  these  cases  except 
in  the  presence  of  some  very  acute  condition  which  makes  the  operation  an 


30  GENERAL  SURGICAL  CONSIDERATIONS 

absolute  necessity,  like  strangulated  hernia,  intestinal  obstruction  due  to  a 
mechanical  cause,  etc.,  the  patient  always  has  a  very  much  better  chance  of 
recovery  if  one  postpones  the  operation  until  this  feeling  of  fear  or  premoni- 
tion has  passed  away  and  the  patient  asks  to  be  operated  upon. 

AVe  have  encountered  several  cases  in  which  our  disregard  of  this  condition 
has  resulted  seriously  to  the  patient. 

In  at  least  two  cases  in  our  experience  the  nervous  shock  due  to  the  antici- 
pation of  an  operation  was  so  severe  as  to  kill  the  patient  before  he  was  trans- 
ferred to  the  operating  room.  One  of  these  cases  occurred  in  a  man  about 
sixty  years  of  age  upon  whom  we  had  planned  to  perform  a  prostatectomy. 
The  patient  was  seen  at  8  A.  M.  He  was  normal  in  every  way.  The  urine  was 
normal,  the  blood  pressure  nearly  so,  his  heart  action  w^as  good  and  he  seemed 
m  an  excellent  condition  to  undergo  the  operation,  which  had  been  set  for  10 
A.  M.  The  patient  was,  however,  very  much  frightened  over  the  impending 
procedure.  About  9  :30  his  special  nurse  came  to  the  operating  room  and  said 
that  her  patient  had  been  getting  more  and  more  nervous  so  that  she  w^as 
getting  quite  alarmed  about  him  and  begged  that  we  should  call  at  once  to 
encourage  him.    Upon  reaching  his  room,  immediately,  he  was  found  dead. 

A  second  case  in  a  patient  about  35  years  of  age,  normal  in  every  way 
except  that  he  was  suffering  badly  from  hemorrhoids,  followed  a  very  similar 
course.  The  morning  upon  which  he  was  to  be  operated  the  nurse  said  that  the 
patient's  heart  seemed  to  act  abnormally.  We  went  to  the  ward  at  once  and 
found  the  patient  terribly  frightened  and  almost  pulseless.  The  nurse  reported 
that  she  was  unable  to  count  his  pulse  when  she  had  first  reported.  His  break- 
fast was  ordered  because  we  had  decided  not  to  operate  upon  him.  He  became 
quiet  at  once  and  within  an  hour  his  pulse  was  normal.  Two  days  later  we 
decided  to  perform  the  operation,  because  he  was  again  perfectly  normal  in 
every  way.  As  the  time  approached  he  again  became  very  nervous  and  asked 
the  nurse  to  bring  him  a  glass  of  water.  As  she  proceeded  to  carry  out  his 
wish  she  heard  a  sound  and  upon  turning  to  determine  the  cause  of  this  sound 
she  found  that  he  had  fallen  over  from  the  sitting  posture  which  he  had  oc- 
cupied and  that  he  was  dead. 

There  can  be  no  doubt  but  that  many  cases  that  die  during  operation,  or 
shortly  after,  belong  to  the  group  of  which  these  two  cases  are  characteristic 
examples.  Of  course,  it  would  be  an  easy  matter  to  attribute  fatalities  which 
should  rightly  be  credited  to  bad  surgery  to  this  cause,  precisely  as  the  an- 
esthetic is  blamed  for  a  lot  of  bad  surgery.  On  the  other  hand,  there  can  be  no 
doubt  but  that  deaths  do  occur  as  a  result  of  fear  of  surgical  operations. 

Cathartics  to  be  avoided  in  peritonitis.  Of  course,  the  giving  of  castor 
oil,  as  well  as  all  other  forms  of  cathartics,  and  also  of  any  form  of  food, 
is  absolutely  contraindicated  in  all  those  suffering  from  any  form  of  peri- 
tonitis. The  same  is  true  even  with  greater  force  in  all  cases  of  intestinal 
obstruction,  but  in  these  two  classes  the  gaseous  distension  can  be  most  effectu- 
ally relieved  by  carefully  executed  gastric  lavage,  which  may  be  repeated 
several  times  if  necessary,  and  by  placing  absolutely  nothing  in  the  stomach, 
not  even  water,  giving  nourishment  exclusively  by  rectum,  preferably  bj^ 
the  use  of  an  ounce  of  one  of  the  various  concentrated  predigested  liquid 
foods  diluted  with  three  ounces  of  normal  salt  solution,  through  a  small 
catheter  introduced  into  the  rectum  not  more  than  three  inches.  It  is  best 
to  pour  the  fluid  into  a  funnel  or  a  glass  sj^ringe  attached  to  the  catheter 
and  permit  it  to  enter  the  intestines  by  gravitation.  To  this  treatment 
should  be  added  the  proctoclysis  of  normal  salt  solution  introduced  by  Murphy, 
to  be  described  later. 

In  every  case  belonging  to  these  two  classes  no  form  of  nourishment  and 
no  form  of  cathartics  should  ever  be  given  by  mouth. 


GENERAL  SURGICAL  CONSIDERATIONS  31 

PREPARATION  OF  THE  PATIENT  FOR  OPERATION 

Various  steps.  The  first  step  in  the  preparation  of  the  patient  after  his 
entrance  into  the  hospital,  or  after  an  operation  has  been  decided  upon,  is  to 
once  more  make  a  thorough  examination  either  in  person,  or,  better,  still,  by  an 
equally  competent  associate.  This  examination  should  be  made  independently 
by  the  associate  and  then  the  results  should  be  compared.  It  should  be  made  in 
a  systematic  way  and,  in  hospital  practice,  at  a  stated  period,  so  that  enough 
time  will  be  allotted  to  make  it  thorough.  It  is  true  that  this  plan  increases 
the  amount  of  labor  materially  and  that  it  is  only  very  seldom  that  any  new 
facts  are  determined  by  the  second  examination,  but  it  is  just  in  the  few  cases 
that  it  proves  to  be  of  the  greatest  importance.  It  is  extremely  easy  to  form 
careless  routine  habits  unless  one  constantly  follows  a  definite,  scientific  plan. 
It  does  not  matter  especially  what  plan  is  followed  so  long  as  it  is  compre- 
hensive. 

Below  is  given  an  outline  for  the  routine  history  and  physical  examina- 
tion of  a  patient.  The  outline  may  be  too  complete  for  some  cases,  but  it 
is  well  to  follow  it  as  often  as  possible  as  surprising  points  are  often  brought 
out.  Indeed  the  outline  is  not  as  complete  as  necessary  in  many  cases — but 
is  more  an  indication  of  method. 

It  is  often  necessary  to  make  certain  additional  examinations — ^laboratory 
and  clinical — and  an  outline  of  these  procedures  is  appended.  The  urine 
and  blood  examinations  are  routine  with  us ;  the  others  are  done  when  indi- 
cated. 

CLINICAL   HISTORY 

1.  Statement  of  complaint. 

2.  Family  history.    Present  condition  of  health  of  father,  mother,  brothers 

and  sisters,  if  living ;  causes  of  death,  if  dead. 
History  of  tuberculosis,  cancer,  diabetes,  gout,  hemophilia  and  nervous 
diseases. 

3.  Marital  history.     Years  married.     Condition  of  health  of  husband  and 

children,  if  living.    Causes  of  death,  if  dead.    Miscarriages — their  time 
relation  to  last  successful  pregnancy. 

4.  Hahiis.      Coffee — Tea — Alcohol — Tobacco — Drugs — Habits    of    eating — 

Appetite — Bowels — Sleep. 

5.  Occupation.     Question  closely,  if  indicated,  for  some  feature  of  occupa- 

tion— sanitary   condition,  hours,   nature   of  patient's  particular  job; 
materials  used,  etc. — that  might  throw  light  upon  the  complaint. 

6.  Injuries. 

7.  Operations. 

8.  Insurance. 

9.  Fast  history. 

(a)  Infectious  fevers  (Exanthemata,  diphtheria,  typhoid,  pneumonia, 

malaria,  rheumatism,  chorea,  etc.). 

(b)  Head.    Injuries — headaches. 

(c)  Eyes.     Glasses — failing  vision. 

(d)  Ears.    Tinnitus — abscess — earaches — discharge. 

(e)  Nose.    Colds — catarrh. 

(f)  Teeth.     Abscesses,  ulcerations. 

(g)  Throat.     Sore  throats,  tonsilitis — hoarseness, 
(h)  Neck.    Swelling — stiffness. 

(i)  Cardio  respiratory  system.  Cough,  sputum,  pleurisy,  chest  pain, 
night  sweats,  weakness,  dyspnea,  palpitation,  precordial  pain, 
edema. 


32  GENERAL  SURGICAL  CONSIDERATIONS 

(j)  Gastro-intestiiml  system.  Abdominal  pains — ^vomiting — nausea — 
gastric  distress  —  belching  —  constipation  —  diarrhea  —  hem- 
orrhoids— jaundice — clay  and  tarry  stools. 

(k)  Genito-urinary.  Nocturia —  frequency  —  dysuria  —  pyuria  — 
smoky  urine — hematuria.  Venereal  disease  by  direct  question- 
ing or  symptomatieally. 

(1)  ■  Catamenia.  Time  of  beginning — regularity — period — duration — 
character.    Date  of  last  period. ' 

(m)  Neuro-muscidar  system.  Ataxia  —  dizziness  —  lightning,  joint, 
muscle  and  girdle  pains,  etc. 

(n)     Weight. 
10.     Present  illness. 

PHYSICAL  EXAMINATION 

General  observation.  Development — Nutrition — Evidence  of  pain  or  distress — 
Mental  state. 

Skull.    S^ymmetrj^ — Exostoses — Tender  areas. 

Scalp. 

Face.    Expression — Symmetry,  etc. 

Skin.  Texture — Nutrition — Color  (Anemia,  ITyperemia,  Cyanosis,  Icterus,  Pig- 
mentary) Eruptions — Moisture — Temperature — Vaso-motor  changes — Edema 
— ^Emphysema  — Collateral  circulation — Trophic  changes — Anesthesia — Hy- 
peresthesia— Paresthesia. 

Eyes.  Pupils  —  Sclera?  —  Photopholiia  —  Lachrymation — Diplopia,  Nystagmus, 
Ptosis,  Strabismus,  Exophthalmos,  Lid-lag,  etc.  Conjunctiva.  Gross  dis- 
turbances of  vision. 

Ears.    Discharge — Stigmata — Tophi — Hearing. 

Nose.    Deformities — Obstruction  or  discharge. 

Mouth.    Breath — Ulceration — Exudate — Pigmentation. 

Lips.     Color — Herpes — Ulcerations — Fissures. 

Teeth. 

Gums.    Color — Pyorrhea — Bleeding — Lead  line. 

Tongue.    Color — Coating — Mucous  patches — Tremor — Protrudes  in  mid  line? 

Tonsils.     Size — Exudate — Crypts — Injection. 

Pharynx.     Color — Catarrh. 
.  Palate.    Mid  line  ?    Gag  reflex. 

Larynx.     Voice. 

Neck.     Thyroid — Lymphatic   glands — Pulsations — Stiffness — Tracheal  tug. 

Thorax.  Symmetry  —  Size  —  Shape  —  Expansion  —  Respiration  —  Pulsations  — 
Breasts. 

Heart.  Location  and  character  of  apex  impulse^ — Rhythm — Shocks  and  thrills — 
Borders  of  cardiac  dullness — Aortic  dullness — Character  of  sounds  and  mur- 
murs at  the  various  valve  regions — Friction  rubs. 

Vessels.  Sclerosis — Rate — Quality — Compare  simultaneously  the  two  radial 
pulses  as  to  time,  quality,  etc. 

Blood  pressure. 

Lungs.  Tactile  fremitus — Percussion — Breath  sounds — Vocal  fremitus — Rales — 
Friction  rubs,  etc. 

Abdomen.  Level — Shape — Symmetry — Respiratory  movements — Abnormal  pul- 
sations— Tumor  masses — Tenderness — ^Spasm — Evidence  of  fluid — HernioB. 

Liver.    Area  of  dullness — ^Palpable? — Character  of  surface. 

Gall  hladder.    Palpable  ?     Tenderness. 

Spleen. 

Kidneys.    Palpable  ?    Tenderness  in  costo-vertebral  angles. 

Lymphatic  glands.    (Neck,  axillae,  groin,  epitrochlear. ) 


GENERAL  SURGICAL  CONSIDERATIONS  33 

Bones.    Spine.     (Shape — Deformit}^ — Rigidity — Tenderness.)     Long  bones — Ex- 
ostoses—Irregularities. 
Joints.    Deformities — Pain — Tenderness — Swelling — Motion. 
Extremities. 

(a)  Arms.     Wasting — Involuntary  movements — Tremors — Clubbing  of  fin- 

gers— Nails,  Biceps,  Triceps  and  Periosteoradial  reflexes. 

( b )  Legs.     Varicosities  —  Scars  —  Ulcers  —  Edema — Gait  —  Knee  jerks  — 

Achiles    and  plantar   reflexes,   Babinsky,    Gordon,    Oppenheim   and 
Kernig  tests — Clonus — Rhomberg. 
Rectal   examination.     Fissures — FistulEt> — Hemorrhoids — ^Strictures.      (Prostate 

gland  and  seminal  vesicles — in  the  male.) 
Male  genitalia. 

Penis.    Sores — Discharge,  etc. 

Testicles.    Evidence  of  tuberculosis.    Varicocele — Tumors. 

(See  Rectal.) 
Vaginal  examination. 

External  genitalia. 

Condition  of  perineum. 

Vagina — Discharge. 

Condition  of  cervix — LTlcerations,  etc. 

Size  and  position  of  uterus. 

Tumors. 

Adnexa — Tumors  and  tenderness  and  induration. 
IMinute  local  examination  of  diseased  parts. 
Laboratory  examinations. 

Urine  analysis — routine  for  all  cases. 

Examination  of  stool. 

Gastric  contents  analysis. 

Blood  examination  (red  and  white  cell  count — Hemoglobin — Differential 
count). 

Microscopic  examination  of  vaginal  and  urethral  smears,  etc. 

Sputum  examination,  if  indicated. 

Serum  reactions  (Widal,  "Wasserman,  etc.). 

Examination  of  spinal  fluid. 

Bacterial  cultures  from  discharges,  if  indicated. 

Blood  cultures,  if  indicated. 

Examination  of  body  fluids,  if  indicated. 

Animal  innoculations,  if  indicated. 
Special  examinations. 

Ophthalmoscopic. 

Otoscopic. 

Laryngoscopic. 

Proctoscopic. 

Cystoscopic. 

Bronchoscopic. 

Esophagoscopic. 

Neurological  examination — including  objective  and  subjective  findings  con- 
cerning each  cranial  nerve;  disposition:  emotion;  memory;  intellect,  etc.; 
motor  'system  (atrophy,  weakness,  paralysis,  reflexes,  etc.)  ;  sensation 
(disturbance  of  sensation  of  touch,  pain  and  temperature,  anesthesia, 
paresthesia,  hyperesthesia,  etc.)  ;  vaso-motor  system,  sphincter  disorders, 
sexual  disorders,  etc. 

X-ray  examinations. 

Gastro-intestinal  with  bismuth. 
Bones — Chest — Skull,  etc. 

Tissue  examinations. 

3 


34  GENERAL  SURGICAL  CONSIDERATIONS 

Value  of  conjoint  diagnosis.  Another  element  of  considerable  value  might 
be  mentioned.  If  the  surgeon  knows  that  all  of  his  cases  are  to  be  examined 
thoroughly  by  an  equally  competent  colleague  or  assistant,  lie  is  not  so  prone 
to  become  careless  in  his  personal  examinations  as  his  work  accumulates.  This 
is  one  of  the  most  common  causes  of  reduction  in  the  success  of  surgeons  who 
have  been  eminently  successful.  Aside  from  the  natural  tendency  with  advanc- 
ing years  to  give  less  and  less  attention  to  details  in  the  general  planning  and 
management  of  the  work,  nothing  is  so  certain  to  displace  the  older  members 
of  the  surgical  profession  as  a  tendency  to  make  a  less  thorough  diagnosis  as 
the  years  increase. 

On  the  other  hand  nothing  can  be  of  greater  importance  in  the  development 
of  the  younger  surgeon  than  an  opportunity  to  make  a  large  number  of  careful, 
systematic,  clinical  examinations  in  cases  which  have  been,  or  are  to  be,  care- 
fully examined  by  a  senior  surgeon  of  vast  experience  and  to  be  compelled  to 
make  an  independent  diagnosis  in  these  cases,  especially  is  this  true  if  a 
detailed,  written  diagnosis  is  made  by  each  examiner. 

SPECIAL  METHODS  OF  EXAMINATION 

During  the  past  few  years  a  number  of  methods  have  been  developed  for 
the  examination  of  patients  by  the  use  of  various  vaccines  and  by  variously 
prepared  blood  sera. 

In  the  diagnosis  of  tuberculosis,  s.yphilis,  carcinoma  and  sarcoma  much 
valuable  work  has  been  done.  Many  of  these  methods  are  undergoing  such 
rapid  changes  that  it  will  not  be  wise  to  describe  them  here  in  detail,  because 
better  methods  than  any  now  in  use  will  undoubtedly  be  advanced  in  the  cur- 
rent literature  before  many  months.  It  should  be  stated,  however,  that  all  of 
these  procedures  are  worthy  of  much  attention  and  should  be  considered,  at 
least  when  they  confirm  a  diagnosis  made  by  means  of  older  methods  of 
examination. 

TUBERCULIN  TESTS 

In  cases  of  suspected  tuberculosis,  in  which  no  material  containing  tubercle 
bacilli  can  be  obtained,  demonstrations  of  the  lesion  by  means  of  tuberculin 
tests  is  often  possible.  It  should  be  emphasized,  however,  that  all  types 
of  tuberculin  tests  are  only  to  be  interpreted  in  the  light  of  clinical  history  and 
local  or  general  evidences  of  disease. 

In  ordinary  practice  the  forms  of  tuberculin  test  commonly  used  are  the 
"subcutaneous" — the  "skin  test"  (Von  Pirquet)  or  the  "ophthalmic  test" 
(Wolff-Eisner  and  Calmette).  Each  type  of  test  has  its  useful  field,  but  most 
instructive  clinical  information  is  given  by  tuberculin  subcutaneously  given. 

The  subcutaneous  tuberculin  test.  It  is,  of  course,  necessary  to  here  men- 
tion that  where  sputum  is  thick  with  bacilli,  where  the  physical  signs  at  the 
suspected  focus  are  evident,  or  where  the  clinical  course  of  the  disease  is 
characteristic,  the  injections  are  not  indicated.  Every  effort  should  be  made 
to  find  bacilli  in  the  sputum  by  repeated  examinations  of  fresh  specimens ; 
every  opportunity  should  be  used  to  discover  local  alterations ;  every  detail 
in  the  patient's  history  and  present  condition  should  be  scrutinized.  For,  if 
this  is  not  done,  the  interpretation  of  the  picture  after  the  injections  may  be 
faulty  and  misleading,  and,  perhaps,  the  source  of  much  inconvenience  and 
anxiety  to  the  patient.  If  the  above  conditions  have  been  satisfied  and  one 
still  finds  the  positive  diagnosis  obscure,  although  he  may  strongly  suspect  the 
nature  of  the  disease,  it  is  good  practice  to  advise  the  diagnostic  injections, 


GENERAL  SURGICAL  CONSIDERATIONS  35 

In  order  to  insure  dependable  results,  it  is  quite  essential  that  the  follow- 
ing facts  be  observed : 

The  patient  should  be  under  no  antipyretic  medication  at  the  time  that 
tuberculin  tests  are  being  carried  out.  It  is  a  good  rule  to  stop  all  medication 
a  day  or  two  before  the  time  for  the  proposed  injections. 

The  patient's  temperature  should  be  shown  to  be  within  the  normal  range 
— or  with  very  slight  variations — by  two-hourly  recorded  observations  for 
two  or  three  days  previous  to  the  injections.  The  pulse  and  respiratory  rate 
should  be  likewise  determined. 

The  patient's  physical  signs  at  the  suspected  focus  should  be  accurately 
observed.  This  is  necessary  in  order  that  the  condition  after  the  injections 
may  be  compared  with  that  existing  before. 

The  general  condition  of  the  patient  should  be  noted ;  for  example,  the 
presence  or  absence  of  headache,  of  backache,  or  neuralgia,  or  pain  in  the 
joints,  or  pain  in  such  special  regions  as  the  kidney  or  the  eye. 

The  existing  condition  in  any  surface  lesion  should  be  observed. 

Any  coexisting  ailment,  as  tonsilitis,  gastric  disturbance,  et  cetera,  contra- 
indicates  the  injections. 

It  is  advisable  to  have  the  patient  rest  quietly  at  least  part  of  the  day  pre- 
ceding the  evening  on  which  the  tuberculin  is  to  be  injected.  Sometimes  the 
extra  duties  which  have  to  be  performed  in  view  of  a  few  days'  absence  from 
school  or  office  bring  about  general  or  subjective  changes  which  obscure  the 
reaction. 

The  injections.  The  injections  are  very  conveniently  made  with  an  all- 
glass  hypodermic  syringe  (as  the  Luer).  This  form  of  syringe  is  compact 
and  easily  kept  clean.  The  site  of  the  injections  is  usually  the  soft  tissue  in 
the  interscapular  region,  the  upper  thorax  or  the  flanks.  The  skin  should  be 
prepared  as  for  other  forms  of  hypodermic  medication.  After  the  tuberculin 
solution  has  been  injected,  the  needle  puncture  should  be  sealed  with  cotton 
and  collodion.  This  procedure  lessens  the  danger  of  local  infection  from 
clothing,  and  the  like. 

It  is  our  custom  to  give  the  injections  in  the  dosage  sug^gested  by  Koch  for 
the  "old  tuberculin."  The  initial  injection  consists  of  one  milligram  of  "old 
tuberculin"  and  is  best  given  at  bedtime.  The  patient  is  kept  quiet,  preferably 
in  bed,  all  of  the  next  day.  This  detail  cannot  be  too  strongly  insisted  upon, 
inasmuch  as  sometimes  even  what  may  appear  to  be  slight  disturbances — as, 
for  example,  examination  by  many  people,  a  walk  to  the  dining-room,  an 
exciting  game  of  cards — will  render  observations  of  doubtful  value. 

The  reaction.  This  depends  upon  several  factors,  chief  of  which  are  the 
physical  condition  of  the  patient,  the  dose  of  tuberculin  administered,  the 
environment  of  the  patient,  and  to  some  degree  the  stage  of  the  tuberculous 
process.  The  interpretation  of  the  reaction  is  guided  by  the  observation  of 
several  features  of  its  manifestation.  These  are:  (a)  the  increase  in  tempera- 
ture in  tuberculous  individuals  following  injections  of  tuberculin;  (b)  the 
constitutional  evidences  of  acute  intoxication,  and  (c)  the  local  alterations  at 
the  site  of  the  suspected  lesion.  Each  phase  will  be  considered  somewhat  in 
detail. 

(a)  The  rise  in  temperature.  In  typical  cases,  this  begins  about  eight  hours 
after  the  injections,  although  it  may  be  delayed  for  some  time  longer.  The 
ascent  is  rather  gradual.  In  most  cases,  where  the  tuberculous  process  is  not 
far  advanced,  the  temperature  rises  one  and  one-half  to  three  de,grees  above 
the  normal.  It  may  remain  for  several  hours  at  this  point,  and  then  falls 
quite  rapidly.  The  rise  in  temperature  is  frequently  preceded  by  a  slight  fall. 
In  order  to  appreciate  the  variations  in  the  temperature  curve,  it  is  advisable, 


36  GENERAL  SURGICAL  CONSIDERATIONS 

whenever  possible,  to  have  hourly  observations  as  soon  as  the  temperature 
curve  shows  a  tendency  to  go  upward.  No  rise  in  temperature  of  less  than 
one  and  one-half  degrees  should  be  considered  anything  more  than  suspicious. 
Nor  has  it  appeared  to  us  that  evidence  of  increased  temperature  of  itself 
should  be  considered  positive  proof  of  tuberculous  infection.  It  should  arouse 
such  suspicion  as  will  lead  to  close  investigation  of  the  suspected  focus. 

(b)  The  constitutional  manifestations  of  reaction.  In  typical  cases,  coin- 
cident with  the  rise  in  temperature,  the  patient  may  complain  of  feeling  tired, 
of  headache,  of  pains  in  the  muscles,  of  pains  in  the  joints.  There  is  often  a 
sensation  of  chilliness,  rarely  an  actual  chill.  Anorexia  is  common,  particu- 
larly where  the  febrile  reaction  is  prompt  and  marked.  There  is  occasionally 
nausea;  this  is  not  always  the  case,  however,  as  some  patients  exhibit  either 
of  these  manifestations  of  reaction  without  the  other.  The  constitutional  dis- 
comfort usually  persists  for  a  longer  time  than  does  the  temperature  rise. 

(c)  The  local  evidences  of  reaction.  Commonly,  especially  in  cases  of 
incipient  pulmonary  tuberculosis,  this  feature  is  overlooked,  and  should  there 
be  no  rise  in  temperature  or  constitutional  symptoms,  a  negative  report  is 
returned.  The  careful  examination  of  the  local  alterations  after  injections  of 
tuberculin  should  never  be  neglected.  In  some  cases  it  is  the  only  striking 
feature  of  the  reaction,  and  may  of  itself  be  the  strongest  in  making  a  positive 
diagnosis.  The  local  changes  in  the  lungs  may  make  themselves  manifest  by 
harsher  breath-sounds,  greater  increase  in  transmission  of  the  whispered  voice, 
the  presence  of  rales  where  none  had  before  been  discovered,  or  an  increase  in 
their  number  or  an  alteration  in  their  character.  In  affections  of  the  pleura, 
there  may  be  development  of  a  pleural  friction  rub,  or  in  some  cases  the 
disappearance,  or  the  lessening,  of  one  that  before  existed.  In  joint  distiirb- 
ances  there  is  often  pain  or  soreness,  swelling,  or  impaired  function.  Skin 
lesions  exhibit  greater  vascularity,  with  redness  and  swelling.  In  affections  of 
the  lar^'nx  or  the  various  parts  of  the  eye,  one  frequently  observes  added  evi- 
dences of  engorgement.  In  renal  affections  local  tenderness  or  pain,  with  the 
presence  of  albuminuria,  may  be  noted. 

Duration  of  the  reaction.  In  the  majority  of  positive  cases,  the  evidences 
of  reaction  have  disappeared  within  thirty-six  hours.  Sometimes  the  reaction 
begins  late  and  may  thus  appear  to  be  prolonged.  This  may  be  noted  in  old, 
fibroid  cases.  It  is  essential  that  the  patient  be  kept  at  rest  and  thoroughly 
examined  from  all  standpoints  just  so  long  as  he  presents  any  deviation  from 
his  pre^nously-noted  condition.  In  cases  where  the  reaction  appears  to  be 
especially  late  in  its  onset,  or  prolonged  in  duration,  it  has  always  seemed 
advisable  to  us  to  look  for  other  causes  to  which  the  change  might  be 
ascribed.  "We  have  seen  instances  where  evidences  of  local  infection  at  the 
site  of  the  injections,  tonsilitis  or  gonorrhea,  confused  the  picture. 

Repeated  injections.  AVhen  the  injection  of  one  milligram  of  tuberculin 
produces  no  reaction  as  described,  the  natient  cannot  be  said  to  be  free  from 
infection.  He  should  be  kept  quiet  for  from  three  days  to  one  week  and.  under 
conditions  before  mentioned,  an  injection  of  five  milligrams  of  tuberculin  may 
be  given.  For  at  least  two  days  following  the  second  injection  the  patient's 
condition  should  be  carefully  observed.  If  with  this  second  injection  there  is 
no  effect  produced,  then  after  another  resting  period  of  from  three  days  to  one 
week,  an  injection  of  ten  milligrams  may  be  given,  and  the  patient  observed 
as  before.  To  many  clinicians  a  negative  result  with  the  injection  of  ten  milli- 
srrams  of  tuberculin  is  deemed  all  that  is  necessarv  to  exclude  tuberculous 
infection.  There  are  other  observers,  however  (Koch,  Marx),  who  recom- 
mend that  the  final  dose  of  ten  milligrams  should  be  repeated  before  it  can  be 
said  positively  that  a  suspicious  case  is  free  from  infection.  If  there  is  any 
tendency  shown  to  reaction  of  a  given  dose,  then  it  is  deemed  good  practice  to 


GENERAL  SURGICAL  CONSIDERATIONS  37 

repeat  that  dose  before  larger  doses  are  administered.  In  all  events,  the  injec- 
tions should  not  be  given  at  too  frequent  intervals,  else  an  immunity  may  be 
established  and  no  reaction  result. 

Anaphylactic  reaction  should  be  borne  in  mind. 

Preparations  of  tuberculin  used  for  therapeutic  effect.  The  preparation  of 
choice  is  the  "new  tuberculin"  of  Koch.  The  "bacilli  emulsion,"  the  "watery 
extract"  of  von  Ruck,  and  the  serum  of  Maragliano  are  frequently  used.  The 
injections  are  preferably  given  at  night.  It  is  best  to  keep  the  patient  quiet 
the  day  following.  Examinations  should  be  made  as  Avhen  tuberculin  is  used 
for  diagnostic  purposes.  The  temperature,  the  constitutional  symptoms  and 
the  local  changes  should  be  observed. 

Dosage.  In  giving  the  injections  care  should  be  taken  that  only  freshlj^ 
prepared  solutions  be  used.  If  they  have  been  kept  longer  than  twenty-four 
hours,  it  is  advisable  to  discard  them.  If  they  are  at  all  cloudy  they  should 
not  be  used.  Although  one  cannot  say  that  there  is  any  set  rule  regarding  the 
amount  of  the  be^ginning  injection,  yet  it  appears  to  us  that  working  with  the 
"new  tuberculin"  of  Koch  it  does  not  seem  that  so  small  a  dose  as  one- 
thousandth  milligram  should  be  used.  A\"e  fully  realize  that  even  smaller  doses 
than  this  have  been  recommended,  yet  unless  one  is  giving  such  with  some 
special  scientific  problem  in  view,  these  small  doses  are  frequently  a  waste  of 
time,  and  are  certainly  an  annoyance  to  the  patients.  Doses  of  one  five- 
hundredth  milligram  are  safe,  in  the  majority  of  instances.  They  usually 
produce  recognizable  effects,  and  they  are  not  so  large  as  to  be  dangerous.  If 
larger  doses  are  used  at  the  outset,  a  true  tuberculin  reaction  may  result,  and 
if  these  doses  are  frequently  given,  the  "cumulative"  effect  (prolongation  of 
the  "negative  phase")  may  be  disastrous.  The  effect  on  the  opsonic  index  or 
the  evidences  of  local  or  general  reaction  are  the  only  true  guides  to  the 
amount  of  tuberculin  to  be  injected.  In  view  of  the  difficulties  in  respect  to 
the  former,  the  close  scrutiny  of  the  local  focus  furnishes  most  valuable 
information  regarding  the  size  of  dose  after  the  initial  injection. 

If  no  reaction  other  than  local  follows  the  initial  injections,  then  the  size 
of  the  dose  can  be  gradually  increased,  as,  for  example,  to  one  two-hundredth 
milligram,  to  one  one-hundredth,  one-fiftieth,  one-twenty-fifth,  and  so  on. 
Cumulative  action  may  be  avoided  by  ^giving  the  injections  at  intervals  of 
from  five  to  ten  days,  as  indicated.  "When  possible,  opsonic  estimations  should 
control  the  injection-time.  If  this  is  not  possible,  then  if  at  any  time  there  is 
even  the  slightest  evidence  of  rise  in  temperature,  constitutional  symptoms  or 
marked  aggravation  of  the  process — especially  if  this  is  persistent — in  the 
affected  part,  the  injections  should  be  discontinued  for  a  time.  "When  they  are 
again  begun,  the  dose  should  be  reduced  to  one-half  of  the  one  Avhich  caused 
the  acute  exacerbation.  If  these  details  are  attended  to  then,  as  shown  by 
Jeans  and  Sellards,  in  many  cases  the  satisfactory  progress  of  the  case  is  pos- 
sible without  the  opsonic  estimations. 

Much  harm  has  been  done  patients  by  the  practice  of  pushing  the  use  of 
vaccines  to  high  dosage.  It  is  by  far  better  to  continue  a  dosage  equal  to 
one-half  the  lowest  dose  causing  a  reaction. 

The  "skin  test"  (Von  Pirquet.) — The  cutaneous  reaction.  Apply  a  drop  of 
pure,  "old"  tuberculin  to  the  skin  and  make  through  it  with  the  point  of  a 
scalpel  a  few  very  superficial  incisions.  As  controls,  incisions  are  made  in  the 
bare  skin  and  also  through  a  drop  of  fifty  per  cent,  glycerin.  It  is  aimed  to 
make  the  incisions  so  superficial  that  there  will  be  no  bleeding,  but  frequently 
a  few  small  drops  of  blood  appear  along  the  line  of  incision.  This  seems  in  no 
way  to  interfere  with  the  delicacy  of  the  test.  In  the  beginning  we  allowed 
the  tuberculin  to  remain  on  the  arm  two  or  three  minutes  after  the  incisions 
were  made,  then  covered  it  with  a  small  piece  of  gauze  held  in  place  by  straps 


38  GENERAL  SURGICAL  CONSIDERATIONS 

of  adhesive  plaster.  In  this  way  the  tuberculin  is  kept  a  lon^ger  time  in  con- 
tact with  the  skin.  More  recently  we  have  allowed  the  drops  to  remain  for  at 
least  five  minutes  after  incision  before  covering  them  with  gauze.  This  differ- 
ence in  the  length  of  exposure  has  made  absolutely  no  change  in  our  results 
and  is,  we  think,  of  quite  secondary  importance. 

The  result  of  these  tests  we  have  classified  under  five  headings  : 

1.  Negative  Reactions. — No  redness  or  infiltration  about  the  incisions. 

2.  Slight  Reactions. — Definite  redness  and  some  infiltration  about  the 
incisions. 

3.  -f  Reaction. — Rather  wide  area  of  redness  which  is  definitely  raised. 

4.  -j — [-Reaction. — Wider  area  of  redness  and  more  marked  elevation 
than  -\-. 

5.  -\ — I — [-Reaction. — Unusual  redness  and  a  wide  area  of  infiltration. 

The  ophthalmic  test  (Wolff-Eisner  and  Calmette)  or  conjunctival  reaction. 
Recently  M.  A.  Calmette  has  described  a  new  diagnostic  reaction  with  tuber- 
culin. When  a  drop  of  one  per  cent,  solution  of  tuberculin  is  instilled  into 
the  conjunctival  sac  of  a  patient  suffering  with  tuberculosis,  there  appears  a 
marked  congestion  of  the  conjunctiva,  accompanied  by  edema  more  or  less 
intense,  and  a  sero-fibrinous  exudate.  This  reaction  begins  about  three  hours 
after  the  instillation,  and  reaches  its  maximum  in  about  six  hours.  The  reac- 
tion is  not  accompanied  b}^  temperature  changes,  and  has  little  or  no  incon- 
venience except  the  localized  symptoms  in  the  eye. 

Interpretation.  Negative. — No  discernible  difference  in  the  two  con- 
junctivae. 

Slight  or  doubtful. — Conjunctiva  of  the  eye  receiving  the  injection  a  little 
redder  than  the  other  eye,  but  the  difference  not  marked  enough  to  permit 
the  reaction  to  be  called  definitely  positive.  In  most  instances  the  redness  and 
injection  are  limited  to  the  caruncle. 

-f-. — Definite  palpebral  redness. 
-] — [-. — More  marked  palpebral  redness  with  secretion. 

-| — \--\-. — Palpebral  and  bulbar  redness  with  subjective  symptoms  and  well- 
marked  secretion. 

In  making  the  readings  the  lower  lids  are  well  pulled  down  and  the  patient 
directed  to  move  the  eyes  in  different  planes.  It  will  be  appreciated  that  a 
slight  or  doubtful  reaction  to  a  conjunctival  test  is  quite  different  from  a 
slight  reaction  to  the  cutaneous  test. 

TECHNIQUE  FOR  MICROSCOPICAL  EXAMINATION   OF  BLOOD 

Obtaining  the  blood  from  the  patient.  For  microscopical  examination  the 
blood  is  preferably  obtained  from  the  lobe  of  the  ear,  which  is  cleansed  thor- 
oughly with  alcohol  on  a  sponge,  it  is  then  Aviped  dry  with  sterile  cotton,  rub- 
bing rather  vigorously  so  as  to  produce  a  slight  hyperemia.  The  style  of  needle 
to  be  used  is  of  little  importance.  It  should  be  kept  immersed  in  alcohol  when 
not  in  use.  The  point  of  the  needle  is  inserted  into  the  inferior  surface  of  the 
most  dependent  part  of  the  lobe,  far  enough  to  cause  the  blood  drop  to  form 
without  using  pressure.  The  first  drop  is  wiped  away.  The  next  drop  is 
employed  to  determine  the  hemoglobin.  For  this  purpose  the  Tallquist  hemo- 
globin scale  is  used.  A  bit  of  paper  from  the  book  (which  accompanies 
scale)  is  held  in  apposition  with  the  freshly-formed  droplet.  This  is  never 
allowed  to  dry.  The  color  is  matched  according  to  the  scale  at  once.  This  is 
accurate  enough  for  all  practical  purposes. 

The  Thoma-Zeiss  apparatus.  The  next  step  is  to  fill  the  red  blood  counter 
pipette.  The  Thoma-Zeiss  apparatus  is  used.  A  fresh  drop  is  allowed  to  form ; 
the  tip  of  the  pipette  is  placed  against  the  drop  (never  touching  the  ear)  the 


GENERAL  SURGICAL  CONSIDERATIONS 


39 


blood  is  sucked  up  to  the  mark  0.5  (precision  is  essential),  the  tip  is  wiped  off 
and  the  pipette  is  plunged  into  normal  NaCl  or  Hay  em's  solution;  the  pipette 
is  filled  with  this  up  to  the  mark  101  and  then  twirled  about  so  that  the  salt 
solution  and  blood  become  intimately  mixed.  By  this  procedure  hemolysis  and 
crenation  are  prevented  and  the  blood  is  diluted  two  hundred  times.  The 
next  step  is  to  fill  the  leucocyte  counter.  A  fresh  drop  is  allowed  to  form — 
the  leucocyte  pipette  is  filled  with  blood  to  the  mark  0.5  and  the  tip  is  cleansed 
and  the  pipette  is  then  filled  to  the  mark  1.1  with  three  per  cent,  acetic  acid. 
The  acetic  acid  dissolves  the  hemoglobin  out  of  the  red  cells.  A  slight  inac- 
curacy in  filling  this  pipette  will  cause  a  great  error  in  the  final  result.  The 
dilution  is  1-20  in  the  pipette.  For  making  a  differential  count,  a  drop  of  blood 
is  allowed  to  fall  on  the  end  of  a  glass  slide  or  thin  films  of  blood  are  made  on 
cover-slips.  The  glassware  must  be  absolutely  clean  and  free  from  fat,  etc. 
The  drop  should  be  a  small  one. 

A  bit  of  cotton  is  placed  against  the  patient's  ear  to  catch  a  drop  or  two 
which  may  ooze  out.  The  blood  is  now  ready  for  microscopic  examination. 
The  Thoma-Zeiss  chamber  is  used. 

Counting  erythrocjrtes.  The  pipette  is  then  twirled  again  so  as  to  make 
certain  that  there  is  a  uniform  distribution  of  the  corpuscles  and  a  few  drops 
are  blown  out  (the  part  which  has  not  been  in  the  bulb  contains  mostly  salt 
solution  and  few  corpuscles).    A  drop  is  then  placed  on  the  platform  of  the 


s 

L 

7 

^ 

1 

« 

L 

4 

^ 

L 

t, 

7 

1 

10 

1 

t, 

L 

7 

^ 

^ 

s 

1 

a 

^ 

a 

0      0 

0 
0 

a    o    0 

o  0  0 
n    n 

0 
0^ 

J 

0 

0 

n     o 

3    0 
o  o 

0 

"       0 

°o  oO 

°    0 

O      o 

CI 

0    D 

0     0  0 
O   0 

0    0    0 

\>. 

o 

o  qq 

^0 

O 

0    o 
0  0  0 

3  o  0° 

"o   0 
a     Q 

b 

> 

0      0 

?A 

0  o 

0  0 

\9  Q  Q 

3  O 

'O       0 

o 
o    o 

=    0     o 
0 

?        0 

counter  and  is  covered  with  one  of  the  specially  ground  glasses  which  go  with 
the  instrument.  This  step  requires  care.  There  must  be  no  air  bubbles ;  the 
entire  platform  should  be  covered  and  none  of  the  liquids  should  run  into  the 
moat.  If  these  requirements  are  not  fulfilled,  remove  the  cover-glass,  clean 
the  chamber  and  use  a  new  drop.  When  the  satisfactory  drop  is  obtained, 
allow  the  corpuscles  to  settle  and  examine  with  the  low  power  of  the  micro- 
scope.   Be  sure  that  the  corpuscles  are  evenly  distributed. 

The  following  is  a  quick  and  fairly  accurate  method  of  determining  the 
number  of  erythrocytes.  Altogether  eighty  (5x16)  small  squares  are  counted. 
To  the  total  number  of  cells  counted  four  ciphers  are  added  and  the  result  gives 
the  number  of  cells  in  a  cubic  mm.  In  counting  the  little  squares,  all  the  cells 
touching  the  right  hand  and  upper  boundaries  of  the  square  are  included  in 
count. 

Counting-  the  leucocytes.  The  drop  is  prepared  accordin,g  to  the  same  pro- 
cedure, the  same  precautions  being  used.  The  cells  in  the  entire  field  of  four 
hundred  squares  are  counted.  The  drop  is  wiped  off  and  the  slide  cleaned  and 
this  performance  repeated.     Three  drops  altogether  are  counted.     The  differ- 


40  GENERAL  SURGICAL  CONSIDERATIONS 

ence  between  the  counts  of  the  various  drops  should  not  exceed  eight  at  the 
most.  If  there  is  a  greater  discrepancy,  faulty  technique  is  to  blame.  Deter- 
mine the  leucocyte  count  thus : 

Drop  A — 42. 

Drop  B— 42. 

Drop  C— 46. 

130 

This  sum  divided  by  three  gives  an  average  of  43.33  per  sq.  m.m.  This 
multiplied  by  two  hundred  equals  8,666,  the  number  of  leucocytes  in  a  cu.  m.m. 

Color-index.  By  this  term  is  meant  the  ratio  existing  between  the  hemo- 
globin per  cent,  and  that  of  the  red  cells,  on  the  basis  of  5,000,000  red  cells 
equalling  one  hundred  per  cent,  of  hemoglobin.  By  this  rule  1,000,000  red 
cells  should  correspond  to  twenty  per  cent,  of  hemoglobin. 

In  some  diseases,  such  as  pernicious  anemia,  the  hemoglobin  per  cent,  is 
higher  than  the  red  cell  per  cent,  because  of  the  increased  size  of  cells.  To 
illustrate ;  in  a  given  case  the  hemoglobin  is  thirty  per  cent. ;  the  red  count 
1,000,000,  or  twenty  per  cent. ;  the  color-index  is  3/2 ;  or  in  a  given  case,  e.g., 
the  hemoglobin  is  eighty  per  cent,  the  red  cells  4,200,000  (eighty-four  per 
cent.)    thus: 

4,200,000  80 

xl00=84.     The  color  index=— .95 

5,000,000  84 

Differential  count.  Wright's  stain  is  commonly  used.  If  filtered  daily 
it  keeps  indefinitely  and  is  perhaps  the  best  stain  for  routine  work. 

Staining  of  blood-films.  I.  1.  Make  films  of  the  blood,  spread  thinly,  and 
allow  them  to  dry  in  the  air. 

2.  Cover  the  preparation  with  the  alcoholic  solution  of  the  dye  for  one 
minute. 

3.  Add  water  to  the  alcoholic  solution  of  the  dye  on  the  preparation,  drop 
by  drop,  until  the  mixture  becomes  semi-translucent  and  a  yellowish,  metallic 
scum  forms  on  the  surface.  Allow  this  mixture  to  remain  on  the  preparation 
for  two  or  three  minutes. 

4.  Wash  in  water  (preferably  distilled)  until  the  film  has  a  yellowish  or 
pinkish  tint  in  its  thinner  or  better  spread  portions. 

5.  Dry  between  filter-paper  and  mount  in  balsam. 

Dried  blood-films  may  be  kept  for  some  weeks  without  impairment  of  their 
staining  properties ;  but  if  kept  too  long  will  not  give  good  results. 

MICROSCOPICAL  APPEARANCES  IN  BLOOD-FILMS  STAINED  BY  THE 

METHOD  OF  WRIGHT 

Red  cells  are  orange  or  pink  in  color;  polychromatophilia  and  punctate 
basophilia  (the  granular  degeneration  of  Grawitz)  are  well  brought  out.  The 
nucleated  red  cells  have  deep-blue  nuclei,  and  the  cytoplasm  is  usually  of  a 
bluish  tint. 

Lymphocytes  have  dark  purplish-blue  nuclei,  and  robin 's-egg-blue  cyto- 
plasm in  which  a  few  dark-blue  or  purplish  granules  are  sometimes  present. 

Polynuclear  neutrophilic  leukocytes  have  dark-blue  or  dark-lilac  colored 
nuclei,  and  the  granules  are  usually  of  a  reddish-lilac  color. 

Eosinophilic  leukocytes  have  blue  or  dark-lilac  colored  nuclei.  The  gran- 
ules have  the  color  of  eosin,  while  the  cytoplasm  in  which  they  are  imbedded 
has  a  blue  color. 

Large  mononuclear  leukocytes  appear  in  at  least  two  forms.  Each  form 
has  a  blue  or  dark-lilac  colored  nucleus.    The  cytoplasm  of  one  form  is  pale- 


GENERAL  SURGICAL  CONSIDERATIONS  41 

blue,  and  of  the  other  form  is  blue  with  dark-lilac  or  deep-purple  colored  gran- 
ules, which  are  usually  not  so  numerous  as  are  the  granules  in  the  polynuclear 
leukocytes. 

Mast  cells  appear  as  cells  of  about  the  size  of  polynuclear  leukocytes  with 
purplish  or  dark-blue  stained,  irregular-shaped  nuclei,  and  cytoplasm,  some- 
times bluish,  in  which  numerous  coarse  spherical  granules  of  variable  size  are 
imbedded.  These  granules  are  of  dark-blue  or  of  a  dark-purple  color,  and  may 
appear  almost  black. 

Myelocytes  have  dark-blue  or  dark-lilac  colored  nuclei,  and  blue  cytoplasm 
in  which  numerous  dark-lilac  or  reddish-lilac  colored  granules  are  imbedded. 

The  blood-plates  are  deeply  stained,  and  are  a  prominent  feature  of  nearly 
every  blood  preparation.  They  appear  as  blue  or  purplish,  rounded  or  oval 
bodies,  usually  of  a  diameter  of  a  third  to  a  half  of  that  of  a  red  blood- 
corpuscle.  Sometimes  they  appear  in  groups  or  masses,  and  at  first  sight  may 
be  regarded  as  precipitates.  In  many  instances  they  have  the  appearance  of 
being  within  a  red  corpuscle  and  surrounded  by  an  unstained  zone  of  its 
cytoplasm. 

Malarial  parasites.  The  body  of  a  malarial  parasite  stains  blue,  while  the 
color  of  the  chromatin  varies  from  a  lilac-color  through  varying  shades  of  red 
to  almost  black.  In  the  young  forms  of  the  tertian  and  aestivo-autumnal 
parasite  the  chromatin  appears  as  a  spherical  very  dark-red  body,  while  in 
the  older  forms  of  the  tertian  parasite  it  has  a  more  lilac  or  purplish-red  color, 
and  may  appear  in  the  form  of  a  reticulum.  In  the  intermediate  forms  the 
color  of  the  chromatin  may  present  variations  between  these  extremes.  The 
inexperienced  observer  may  mistake  the  blood-plates  apparently  situated 
within  the  red  blood  cells  for  malarial  parasites.  This  will  not  occur  if  he  bear 
in  mind  that  the  young  parasite  of  all  the  three  kinds  should  present  by  this 
method  a  dark-red  spherical  nucleus,  and  a  cytoplasm  which  is  usually  in  the 
form  of  a  definite  ring.  This  method  of  staining  will  bring  out  dark-red  stain- 
ing granules  in  the  red  corpuscles  harboring  malarial  parasites  provided  the 
stain  after  the  water  has  been  added  to  it  is  allowed  to  remain  on  the  prepara- 
tion for  at  least  five  minutes,  and  not  to  decolorize  for  so  long  a  time  as  with 
the  ordinary  stain. 

Staining  method.  II.  A  very  satisfactory  method  is  to  use  Jenner's  stain 
(which  may  be  obtained  at  any  reputable  supply  house)  and  methylene- 
blue.  The  blood  film  is  allowed  to  dry  in  the  air.  Jenner's  stain  is  dropped 
on  the  slide  and  allowed  to  act  for  two  minutes.  This  is  then  washed  ofi^  and 
Loeffler's  blue  is  allowed  to  act  for  two  minutes.  (If  Jenner's  stain  is  fresh 
and  of  full  strength  this  step-  is  superfluous.)  This  is  then  washed  off  and 
the  smear  is  allowed  to  dry  in  the  air.  It  is  now  ready  for  examination.  A 
drop  of  cedar  oil  is  placed  on  the  slide  and  the  smear  is  examined  with  the  oil 
immersion  lens. 

Staining  method.  III. — The  Ehrlich  tricolor  mixture.  The  Ehrlich  tri- 
color mixture  has  for  years  been  the  most  popular  stain  with  many  workers. 
The  objections  to  it  are  (1)  that  it  is  difficult  to  prepare  a  good  stain,  and  (2) 
that  the  films  must  be  fixed  by  heat.  (The  first  objection  may  be  overcome 
by  sending  to  Walter  Dodd,  apothecary  to  the  Massachusetts  General  Hospital, 
who  furnishes  an  absolutely  reliable  stain.    Arneill.) 

A  drop  of  the  stain  is  spread  over  the  film,  allowed  to  remain  five  minutes 
or  more,  and  washed  off  with  water.  (It  is  impossible  to  overstain.)  The 
specimen  should  look  orange-yellow ;  if  it  is  brown  or  red,  it  is  underheated — 
not  overstained.  If  overheated,  everything  is  blurred  and  dim  under  the 
microscope.  Hewes  improves  the  definition  of  the  nuclei  by  pouring  upon  the 
film  for  a  second  or  two  a  saturated  aqueous  solution  of  methylene-blue,  after 


42  GENERAL  SURGICAL  CONSIDERATIONS 

the  triple  stain  has  been  washed  off  with  water.  This  also  brings  out  the 
malarial  parasite. 

Differential  count.  For  this  purpose  the  carefully  stained  specimen  is 
used.  The  oil  immersion  lens  is  used  and  the  slide  is  moved  about  by  means 
of  a  mechanical  stage.  For  ordinary  purposes  a  count  of  a  hundred  white  cells 
sufifices.  If  the  relative  percentage  of  the  various  kinds  of  white  cells  differ 
from  the  normal  for  the  sake  of  accuracy  it  is  well  to  count  between  three  hun- 
dred and  five  hundred.    As  the  cells  are  counted  they  are  recorded  in  groups. 

Normal  differential  counts.  Origin  of  the  different  varieties  of  physiologic 
leukocytes. 

I.  The  myelogenous  group.     (From  the  bone-marrow.) 

(a)  Poly(morpho)  nuclear. 

(b)  Eosinophiles. 

(c)  Mast-cells. 

(d)  Large  mononuclear  cells. 

II.  The  lymphogenous  group.     (From  adenoid  tissue.) 
Lymphocytes  of  all  sizes. 

Normal  per  cent,  of  each  variety. 

(a)  Small  lymphocytes    20-30  per  cent. 

Large  lymphocytes 4-8  per  cent. 

(b)  Polymorphonuclear  neutrophiles  62-70  per  cent. 

(c)  Eosinophiles    1/2-4  per  cent. 

(d)  "Mast-cells"  I/4O-I/2  per  cent. 

In  infancy  the  percentage  of  lymphocytes  is  much  larger  (40  to  60),  and 

the  polymorphonuclear  only  18  to  40  per  cent. 

Poorly-nourished,  debilitated  people  show  an  excess  of  lymphocytes  and  a 
diminution  of  the  polynuclear  cells.  The  opposite  condition  prevails  in  vig- 
orous health. 

Pathologic  leukocytes.  1.  Myelocyte.  This  is  a  mononuclear  neutrophile, 
and  has  many  points  of  resemblance  to  the  polynuclear  neutrophile ;  it  is  the 
same  cell  in  an  early  stage  of  growth. 

This  cell  makes  up  the  larger  portion  of  the  leukocytes  of  the  marrow,  and 
differs  from  any  variety  found  in  normal  blood. 

It  is  found  in  the  blood  in  various  diseased  conditions,  and  resembles  very 
closely  the  large  lymphocytes,  differing  only  in  possessing  neutrophile  gran- 
ules. It  differs  from  the  polynuclear  neutrophile  in  the  shape  of  its  nucleus, 
but  the  granules  in  both  are  alike.  The  nucleus  is  usually  spherical  or  egg- 
shaped,  and  is  in  close  contact  with  the  cell-wall  for  a  comparatively  large 
portion  of  its  extent.     (Arneill.) 

Eosinophilic  myelocytes.  ^Myelocytes  having  eosinophile  instead  of  neu- 
trophile granules  occasionally  occur. 

The  eosinophile  granules  do  not  all  take  the  same  stain;  some  are  darker 
than  others. 

ATYPICAL  CELLS 

I.  Degenerated  or  moribund  leukocytes.  (1)  A  homogeneously  stained 
mass  looking  like  a  washed-out,  structureless  nucleus  that  has  lost  its  proto- 
plasm and  become  ragged  at  the  edges  (karyolysis). 

(2)  The  same  intensely  stained. 

(3)  Vacuolization  of  the  neucleus  or  of  the  protoplasm. 

In  the  granular  leukocytes  the  granules  are  scattered  about  the  field,  and 
the  neucleus  is  pale,  structureless,  and  deformed. 

II.  Transitional  neutrophile.  Between  marrow-cell  and  polymorpho- 
nuclear. 


GENERAL  SURGICAL  CONSIDERATIONS  43 

III.  Turck's  "stimulation  forms."  Described  by  Weil  as  nongranular 
myelocytes.  They  are  associated  with  stimulation  of  the  bone-marrow,  grave 
anemia,  and  all  conditions  in  which  there  is  a  leukocytosis, 

PATHOLOGICAL  CONDITIONS  OF  THE  BLOOD 

Classification.    The  following  deviations  from  the  normal  may  be  observed : 

1.  Diminution  in  hemoglobin. 

2.  Increase  or  diminution  in  the  red.  count. 

3.  Increase  or  diminution  in  the  white  count. 

4.  Alteration  in  color-index. 

5.  Diminution  in  the  specific  gravity. 

6.  Alterations  in  the  size  and  shape  of  the  red  cells — i.e.,  poikilocytosis. 

7.  Alterations  in  the  staining  properties  of  the  red  cells — i.e.,  polychro- 
matophilia. 

8.  Presence  of  abnormal  forms  of  red  cells. 

9.  Presence  of  abnormal  forms  of  white  cells. 

10.  Alteration  in  the  normal  ratio  of  different  varieties  of  white  cells. 

11.  Presence  of  parasites  in  the  blood. 

Polychromatophilia.  With  special  stains  certain  of  the  red  cells  take  on  a 
darker  color  than  the  remainder  of  the  cells,  the  tint  varying  with  the  stain 
used.  This  is  due  to  a  degenerative  process,  which  changes  the  staining  prop- 
erties of  the  cells,  so  that  they  take  up  several  colors. 

Granular  degeneration  of  red  cells  (Grawitz)  or  punctate  basophilia  of  red 
cells.  In  certain  diseases — malaria,  lead-poisoning,  severe  anemia,  etc.,  red 
cells  often  show  small,  bluish  granules.  These  are  well  brought  out  by 
Wright's  stain.  The  weight  of  evidence  suggests  that  they  are  remnants  of 
nuclei.    Red  corpuscles  harborin,g  malarial  parasites  often  show  these  granules. 

Abnormal  forms  of  red  cells — Nonnucleated :  (a)  microcyte — a  very 
small  red  cell;  (b)  megalocyte — a  very  large  red  cell. 

Nucleated:  (a)  microblast;  (b)  normoblast;  (c)  megaloblast;  (d) 
atypical  forms  of  nucleated  red  cells — called  metrocytes  by  some  authors. 

Microblast.  A  very  small  red  cell,  made  up  chiefly  of  a  nucleus  similar  to 
that  of  the  normoblast.  There  is  a  narrow  rim  of  protoplasm  around  the 
nucleus.    It  has  perhaps  the  same  significance  as  the  megaloblast. 

Normoblast.  It  differs  from  the  normal  red  cell  in  having  a  deeply-stained, 
round  nucleus,  about  one-half  the  diameter  of  the  whole  cell,  situated  some- 
what eccentrically.  At  times  the  nucleus  is  so  situated  that  it  looks  as  if  the 
cell  were  extruding  it. 

Megaloblast.  This  does  not  occur  anywhere  in  the  healthy  adult  body. 
It  is  found  in  the  early  fetal  marrow,  and  in  the  marrow  and  blood  of  grave 
forms  of  anemia.  According  to  Ehrlich,  the  megaloblast  indicates  the  pres- 
ence of  the  fetal  types  of  blood  formation.  It  is  a  grave  prognostic  sign,  and 
when  present  in  excess  of  normoblasts  it  indicates  a  pernicious  form  of  anemia. 
The  only  exception  which  clinicians  have  found  to  this  view  is  the  fact  that  the 
anemias  due  to  intestinal  parasites,  and  showing  pernicious  blood  condition, 
may  recover  under  appropriate  treatment. 

Megaloblasts  may  be  found  in  milder  forms  of  anemia,  but  the  normoblast 
is  the  prevailing  type.  The  typical  megaloblast  is  a  very  large  red  cell,  at 
times  twice  as  large  as  the  average  (11  to  20  microns  in  diameter).  Its  proto- 
plasm frequently  shows  marks  of  degeneration  (polychromatophilia).  The 
nucleus  is  very  large  and  pale,  filling  most  of  the  cell,  thus  contrasting  greatly 
with  the  normoblast.  It  does  not  stain  evenly,  but  has  a  mesh-like  appearance, 
with  darker  and  lighter  areas.    The  entire  cell  reacts  differently  with  Wright's, 


44  aENERAL  SUROICAL  CONSIDERATIONS 

Ehrlich's  triple,  and  the  eosin-hematoxylon  stains  (see  description  of  these 
stains).    The  cell  may  be  circular,  but  is  more  often  oval  or  somewhat  irregular. 

Myelocyte.  This  cell  is  a  mononuclear  neutrophile,  and  has  many  points 
of  resemblance  to  the  polynuclear  neutrophile — in  fact,  it  is  the  young  form 
of  that  cell.  It  differs  from  the  large  lymphocyte  chiefly  in  being  larger  and 
having  neutrophile  granules.  Its  nucleus  is  usually  spherical  or  egg-shaped, 
and  is  in  close  contact  with  the  cell-wall  for  a  comparatively  large  portion  of 
its  circumference.    Its  average  diameter  is  15.75  microns. 

Eosinophilic  myelocytes.     The  myelocyte  rarely  shows  eosinophile  granules. 

The  Ehrlich  triacid  stain  alone  differentiates  the  myelocyte  from  the  large 
lymphocyte — by  means  of  its  granules.     (Arneill.) 

Coagulation  of  blood — Estimation  of  the  time  and  completeness  of  coagula- 
tion. Normally  clotting  occurs  in  about  three  minutes,  but  in  the  exanthemata, 
in  the  various  forms  of  the  hemorrhagic  diathesis,  in  obstruction  of  the  biliary 
tract  with  or  without  jaundice,  and  in  the  various  anemias  it  may  be  very  much 
delayed. 

Bogg's  coagulometer  (modified  Russell  and  Brodie)  consists  of  a  glass  cone 
inverted  in  a  moist  chamber,  an  air  inlet  through  which  air  is  blown  at  inter- 
vals by  means  of  a  rubber  bulb.  A  small  opening  in  the  top  permits  the  air  to 
escape  from  the  moist  chamber.  A  drop  of  blood  is  placed  upon  the  tip  of  the 
glass  cone,  which  is  then  quickly  inverted  into  the  moist  chamber.  The  air 
is  then  injected  at  intervals  of  a  few  seconds  and  the  motion  of  the  corpuscles 
is  watched  with  the  low  power  of  the  microscope.  Coagulation  is  complete 
when  motion  ceases,  or  when  cells  spring  back  to  original  position  when  cur- 
rent of  air  ceases. 

Wright's  method.  This  method  consists  in  the  use  of  a  set  of  from  six  to 
twelve  capillary  tubes  (0.01  to  0.0125  inch  in  diameter),  into  which  a  column 
of  blood  is  aspirated.  The  tubes  are  placed  perpendicularly  in  a  rack,  and  at 
regular  short  intervals  the  blood  is  blown  from  each  one  of  them.  When  it 
becomes  impossible  to  blow  it  out,  coagulation  has  set  in  and  the  time  is  noted. 

Hayden  thinks  he  can  distinguish  between  secondary  and  pernicious  anemia 
by  the  incomplete  formation  of  serum  in  the  latter. 

Widal  test  as  an  aid  in  the  diagnosis  of  typhoid  fever.  (1)  Serum. 
In  hospital  work,  where  a  centrifugal  machine  is  at  hand ;  it  is  best  to  use 
blood-serum.  It  is  obtained  as  follows:  A  piece  of  glass  tubing  (small  bore) 
is  draw^n  out  to  a  fine  point,  and  rubber  tubing  attached  to  the  large  end.  One 
or  two  large  punctures  are  made  in  the  finger  (which  has  been  well  massaged 
previously),  the  fine  point  of  the  tube  placed  in  the  drop  and  suction  made  with 
the  mouth  till  considerable  blood  is  drawn  into  the  pipette.  This  is  sealed 
by  holding  the  pointed  end  in  the  flame  of  a  match,  and  immediately  centrif- 
ugated.  The  clot  should  be  loosened  around  the  edge  to  allow  the  escape  of 
serum.  A  file-mark  is  made  at  the  junction  of  clot  and  supernatant  serum. 
With  the  finger  over  its  top,  break  the  tube  and  blow  out  the  serum  from 
the  upper  piece  into  a  receptacle ;  or,  probably  a  more  satisfactory  method  is 
to  use  the  Wright  capsule.  By  sealing  both  ends  of  the  capsule  the  contents 
will  keep  for  some  time.  If  a  urotropin  or  hexamethylenetetramine  tablet 
is  balanced  on  its  edge  on  a  coin  and  ignited,  it  will  give  sufficient  heat  to  seal 
the  capsule,  and  is  a  very  handy  substitute  for  an  alcohol  lamp. at  the  bed- 
side. If  desired,  dilutions  without  limit  can  be  made  with  this  serum  as  fol- 
lows: One  drop  is  placed  in  a  small  glass  dish  or  on  a  slide  and  nine  drops 
of  salt  solution  added,  giving  a  dilution  of  1  to  10.  A  dilution  of  1  to  20  is 
obtained  by  taking  one  drop  of  this  1  to  10  dilution  and  adding  to  it  one  drop 
of  salt  solution.  A  dilution  of  1  to  40  is  obtained  by  taking  one  drop  of  the 
1  to  10  dilution  and  adding  to  it  three  drops  of  diluting  fluid,  etc.     The  same 


GENERAL  SURaiCAL  CONSIDERATIONS  45 

pipette  must  be  used  for  measuring  the  drop  of  serum  and  the  water  in  order 
to  secure  accuracy. 

Whole  blood  method.  In  private  practice  this  is  more  easily  carried  out 
than  the  above. 

(1)  An  accurate  dilution  of  1  to  10,  1  to  20,  or  1  to  40  can  be  made  with 
a  white-blood  counter,  using  distilled  water  as  a  diluting  fluid. 

(2)  A  convenient  and  easily  applied  method  (especially  if  the  preparation 
is  to  be  sent  by  mail)  is  to  allow  a  good-sized  drop  to  dry  on  a  cover-slip  or 
glazed  paper.  If  paper  has  been  used,  cut  out  the  blood-drop  and  place  in  a 
test-tube  containing  two  drops  of  water;  by  a^gitating  it  the  blood  will  dis- 
solve. To  obtain  a  dilution  of  1  to  10,  eight  drops  of  water  or  bouillon  are 
added. 

The  culture  of  the  typhoid  bacillus.  A  young— eighteen  to  twenty  hours 
old  typhoid  culture  is  required ;  it  must  be  actively  motile.  It  may  be  grown 
on  agar  or  in  peptone  bouillon,  in  the  thermostat  at  37  degrees  C.  The  disad- 
vantage of  the  bouillon  is  that  the  growth  is  often  very  small.  Stock  cultures 
are  grown  on  agar  at  room  temperature,  and  are  transplanted  about  once  a 
month. 

Actively  motile  cultures  show  the  clumping  best. 

Preparation  of  specimen  for  microscopical  examination.  A  drop  of  the 
blood  or  serum  diluted,  1  to  10,  is  placed  upon  a  cover-glass.  Mix  it  (thor- 
oughly, to  separate  bacilli)  with  a  bouillon  culture  of  the  typhoid  bacillus  to 
desired  dilution;  as  one  drop  of  each  (serum  and  bouillon)  equals  a  1  to  20, 
one  of  serum,  and  three  of  bouillon  equals  1  to  40  dilution,  etc.  A  concave 
slide,  with  vaselin,  is  placed  upon  the  cover-glass,  thus  giving  a  hanging 
drop,  and  the  preparation  immediately  examined  under  the  microscope.  A 
control  slide  should  be  made  with  distilled  water  for  comparison.  The  prep- 
aration should  now  be  carefully  examined  every  few  minutes  for  loss  of  motility 
and  signs  of  clumping.  The  length  of  time  for  the  development  of  this 
phenomenon  should  be  noted. 

Instead  of  the  bouillon  culture  a  suspension  made  from  fresh  agar  culture 
mixing  well  with  a  little  salt  solution)  may  be  used.  The  drop  should  be 
examined  at  beginning  of  test  to  be  sure  that  there  is  no  clumping. 

THE  MICROSCOPICAL  EXAMINATION  OF  FECES 

The  "three  drop"  method  described  under  gastric  analysis  is  useful. 
Preparations  must  be  made  very  thin.  If  the  stool  as  passed  is  firm,  it  may 
be  diluted  with  normal  salt  solution. 

Thin  smears  may  be  made  on  cover  slips,  dried  and  stained  by  Unna's 
polychrome  methylene-blue,  Gram's  stain  or  Smithies'  colored-agar  method. 
It  is  best  to  examine  stools  for  parasites  unstained. 

Among  the  common  pathologic  findings  are — undigested  food,  especially 
meat  and  fat  (pancreatic  disease),  blood,  pus,  mucus,  Oppler-Boas  bacilli 
(cancer  of  stomach),  yeasts  and  sarcines  (gastric  or  intestinal  stagnation  of 
benign  type),  tissue  bits  (malignant  cells  in  cancer  of  large  bowel),  crystals 
(hemin,  triple  phosphate,  leucin,  tyrosin,  cholesterin,  fatty  acid),  moulds, 
torulee,  leptothrix  and  intestinal  parasites,  particularly  protozoa. 

Varieties  of  parasites.  The  common  intestinal  parasites  in  the  middle-west 
are :    . 

I.     The  Cestodes  (tape-worms). 

(a) — Tcenia  saginata  (common  tape-worm). 

(b) — Tcenia  splium  (from  measly  pork). 

(c) — Tcenia  nana  (dwarf  tape-worm — common  in  children). 


46  GENERAL  SURGICAL  CONSIDERATIONS 

(d) — BoihriocepJtalus   latus    (Russian   tape-worm,   causing  marked 

anemia). 
(e) — Tcenia  echinococcus.     (Contracted  in  man  from  food  or  associa- 
tion with  dogs  or  sheep.) 
II.     StrongyUdce  (round  worms). 

(a) — Ankylostoma  diiodenale — or  hookworm.  (Necator  Americaniis.) 
(Found  in  small  intestines  especially  in  people  south  of  the  ''Mason 
and  Dixon  line."  Causes  anemia  and  characteristic  physical 
changes.) 
(b) — Ascaris  lumhricoides.  (The  most  common  parasite  of  man, 
especiall}^  children.  Inhabits  small  intestines,  may  be  vomited 
up.) 
(c) — Oxyuris  vcrmicnlaris  or  "pin  or  seat"  worm  of  children. 
(Very  common ;  male  1/6  inch  long  and  female  14  inch  long. 
Male  has  a  curved  tail.  Mature  in  cecujn  and  colon  and  then 
wander  to  rectum,  working  out  about  anus  at  night.  May  enter 
vagina  or  urethra  or  get  beneath  prepuce.)  ' 

III. 

(a) — Trichomonas. — Connnon   in   intermittent   diarrhea  in   patients 
who  have  drunk  contaminated  well  water,  or  eaten  contaminated 
vegetables,  fruits,  etc.    This  parasite  has  a  pear-shaped  body  about 
18x10  microns.     Three    (often  four)    flagella  arise  from  anterior 
end.    There  is  a  lateral  undulating  membrane. 
(b) — Cercomonas. — An  organism  similar  to  the  above,  but  with  no 
flagella  or  undulating  membrane.     It  is  found  under  similar  cir- 
cumstances. 
(c) — Balantidium  coll. — A  common  parasite  of  hogs  and  not  infre- 
quently  associated  with   periodic  or   chronic  diarrhea  of  people 
residing  in  rural  communities.     It  is  from  60  to  100  microns  long 
and  50  to  70  microns  broad.     The  organism  has  a  peristome  at 
its  anterior  end,  and  a  row  of  cilia  almost  encircling  the  ectosarc. 
IV.     Rhizopoda  (should  be  identified  by  an  expert). 

(a) — Entameha   coir. — Common   concomitant   infection    in   chronic 

diarrhea.    Said  not  to  be  pathogenic,  but  this  is  disputed, 
(b) — EntamebOf  histolytica. — Pathogenic  ameba  and  associated,  ap- 
parently casually,  with  acute  and  chronic  diarrhea. 
It  is  of  the  greatest  importance  for  the  surgeon  to  be  familiar  with  these 
intestinal  parasites  and  to  look  for  them  in  cases  coming  under  treatment  for 
any  one  of  a  number  of  unusual  conditions,  or  for  anemia,  dysentery,  diges- 
tive disturbances,  in  order  that  the  patient  may  not  be  exposed  to  a  useless  or 
harmful  operation,  which  can  be  avoided  by  removing  the  parasites  or  their 
original  cause. 

GENERAL  PREPARATION  OF  THE  PATIENT 

In  this  systematic  examination  many  things  are  considered  w^hich  may 
not  have  any  bearing  upon  any  given  case  in  question,  but  when  applied  to 
all  the  cases  in  practice  each  point  is  of  more  or  less  importance. 

Of  course,  the  systematic  analysis  of  cases  must  not  be  supposed  to 
render  superfluous  the  judgment  and  practical  experience  of  the  surgeon  or 
physician  who  makes  the  examination.  A  thorough  system,  good  judgment, 
and  a  wide  experience  will  result  in  the  accomplishment  of  benefit  to  the 
patient  when  they  are  employed  simultaneously. 

After  all  of  the  circumstances  present  in  the  case  have  been  determinecl 
the  necessary  preparations  for  the  operation  may  proceed, 


GENERAL  SURGICAL  CONSIDERATIONS  47' 

Concomitant  diseases.  If  there  exists  serious  disease  of  one  of  the  important 
organs,  aside  from  the  condition  to  be  relieved  by  the  operation,  i.  e.,  if  the 
bloodvessels,  heart,  lungs,  kidneys,  liver,  pancreas  or  spleen,  or  the  blood  itself, 
be  seriously  impaired,  it  is  well  to  overcome  such  fault  unless  it  is  directly 
the  result  of  a  condition  which  is  to  be  relieved  by  the  operation  itself  and  will 
probably  improve  much  more  rapidly  after  than  before  the  operation.  This 
is  especially  true  in  patients  suffering  from  anemia.  It  such  anemia  depends 
upon  a  loss  of  blood  which  will  be  stopped  by  the  operation,  then  the  recovery 
will  usually  be  exceedingly  rapid  after  the  operation  has  been  performed;  if 
due  to  other  causes  the  patient's  recovery  will  be  very  slow  unless  the  anemia 
is  relieved  before  the  operation  is  done.  If  no  important  organ  is  seriously 
impaired  it  is  much  better  not  to  worry  the  patient  unnecessarily  before  the 
operation.  As  a  rule,  long-continued  preparatory  treatment  leaves  the  patient 
in  a  much  less  favorable  condition  for  a  surgical  procedure  than  a  very  short 
and  simple  preparation  which  serves  to  put  the  kidneys,  the  skin  and  the 
alimentary  canal  in  a  state  favorable  to  the  elimination  of  the  waste  products. 

The  day  before  operation.  During  the  day  before  the  operation  the  patient 
should  be  kept  on  light  diet,  consisting  of  sterilized  food,  preferablj^  broth  or 
gruel,  and  allowed  an  abundance  of  good  water,  preferably  hot,  in  order  to 
favor  elimination  through  the  kidneys.  A  non-irritating  cathartic  should  be 
given  and,  if  possible,  a  warm  bath.  For  several  years  w^e  have  given,  as  a 
rule,  two  ounces  of  castor  oil  in  the  foam  of  beer  or  malt  extract  the  day 
before  an  operation,  and  a  large  soap  and  water  enema,  or  one  consisting  of 
normal  salt  solution,  on  the  morning  of,  or  on  the  evening  before,  the  operation. 
In  this  manner  the  patient  is  relieved  in  a  relatively  short  time  of  much  waste 
matter  and  is  consequently  removed  from  the  likelihood  of  absorbin,?  the 
products  of  decomposition  which  may  be  present  in  the  alimentary  tract. 
We  have  found  that  so  large  a  dose  of  castor  oil  is  borne  perfectly  by  almost 
all  patients,  and  that  it  does  not  give  rise  to  disturbance,  pain  or  exhaustion. 
"We  have  also  found  that  foam  of  beer  or  malt  extract  disguises  the  oil  so 
thoroughly  that  those  who  are  ordinarily  nauseated  very  readily  will  bear 
this  method  without  annoyance. 

Prolonged  preparatory  treatment  condemned.  In  the  vast  majority  of 
patients  this  amount  of  preparation  suffices  to  relieve  the  body  of  any  burden 
it  may  possess  which  might  interfere  with  the  progress  of  healing,  or  the 
normal  course  of  convalescence.  In  other  words,  the  patient  approaches  the 
operation  in  a  comparatively  clean  condition;  his  strength  has  not  been  im- 
paired by  confinement  and  his  nervous  system  has  not  suffered  by  looking 
forward  to  the  operation  for  a  long  time.  Some  years  ago  we  had  the  oppor- 
tunity to  observe  the  eff'ect  of  waiting  for  a  number  of  days,  and  sometimes 
for  several  weeks,  to  allow  the  patient  to  get  into  a  more  favorable  condition 
for  operation,  and  we  are  positive  that  as  a  rule  the  practice  is  bad.  The 
exceptions  are  in  those  patients  in  whom  the  heart,  the  kidneys  or  the  blood 
are  too  seriously  impaired,  and  who  might  be  placed  in  a  better  state  by  wait- 
ing; and  in  cases  in  which  infection  is  present  which  may  become  circumscribed 
or  may  be  eliminated  by  delay. 

We  will  refer  to  these  conditions  again  in  connection  with  patients  in  whom 
they  are  present ;  and  will  especially  refer  again  to  old  age,  because  elderly 
patients  bear  many  operations  remarkably  well  if  they  are  not  confined  before, 
and  only  for  a  short  time  after,  the  operation,  while  quite  the  opposite  is  true 
if  this  precaution  is  overlooked. 

Transfusion  of  normal  blood.  In  patients  sufferin^g  from  anemia,  especially 
secondary,  it  is  often  of  great  importance  to  improve  the  condition  of  the 
blood  by  direct  transfusion  of  normal  blood,  particularly  if  the  patient's  per- 
centage of  hemoglobin  is  very  low  and  if  the  character  of  the  blood  shows 


48  GENERAL  SURGICAL  CONSIDERATIONS 

that  there  has  been  a  great  loss  or  a  great  destruction  of  important  elements. 
The  necessary  precautions  and  the  method  advised  will  be  discussed  in  a 
special  chapter  on  transfusion  of  normal  blood.  The  time  and  quantity  must 
depend  upon  the  condition  of  the  patient. 

If  the  hemorrhage  has  stopped  it  is  usually  well  to  make  a  transfusion 
and  await  the  effect.  If  the  blood  improves  from  day  to  day  the  operation 
may  be  postponed,  if  not,  it  is  well  to  make  a  second  transfusion  just  before 
beginning  the  operation  (to  which  the  transfusion  is  preliminary)  and  just 
after  concluding  it.  The  question  of  amount,  selection  of  donor,  etc.,  will  be 
discussed  later. 

THE  FIELD  OF  OPERATION 

Immediate  preparation  sufficient.  In  hospitals  where  many  operations  are 
performed  on  the  same  day,  so  that  the  time  spent  upon  each  case,  imme- 
diately preceding  an  operation,  is  of  importance,  it  may  be  well  to  prepare 
the  field  of  operation  on  the  day  before,  but  this  is  done  simply  as  a  conveni- 
ence, and  not  because  it  is  better  than  it  would  be  to  prepare  the  field  of 
operation  immediately  before  beginning  to  operate.  For  months  at  a  time  we 
have  followed  the  latter  plan  without  having  a  single  wound  infected,  and 
other  surgeons  have  had  the  same  experience,  hence  there  can  be  no  good 
reason  for  insisting  upon  having  the  field  of  operation  prepared  one  or  more 
days  before  the  operative  procedure.  However,  this  may  be  done  as  a  matter 
of  convenience. 

Details  of  surface  preparation.  The  important  point  in  preparing  a  sur- 
face for  operation  lies  in  thorough  washing  with  soap  and  water;  anything 
that  is  accomplished  beyond  this  is  of  little  importance,  provided  the  washing 
process  has  been  done  carefully  and  thoroughly.  In  our  practice  the  steps 
taken  in  preparing  the  field  of  operation  are  as  follows :  1,  Thorough  scrub- 
bing with  soft  soap  and  warm  water  with  a  moderately  stiff  brush ;  2,  AVashing 
the  surface  with  a  piece  of  aseptic  gauze  saturated  with  fresh  water,  because 
the  epithelial  scales  which  have  been  loosened  with  the  brush  are  easily 
removed  in  this  manner;  .3,  Soaping  and  shaving  the  field  of  operation;  4, 
Washing  again  with  aseptic  gauze  and  sterile  water;  5,  Washing  the  surface 
with  commercial,  i.  e.,  about  ninety-five  per  cent.,  alcohol ;  6,  Washing  with  a 
solution  of  corrosive  sublimate,  one  part  in  two  thousand. 

In  many  instances  only  the  first  four,  or  the  first  five,  steps  were  taken  and 
always  with  the  same  results,  consequently  we  are  confident  that  careful 
washing  of  the  surface  with  soap  and  water  is  the  important  part,  but  as  there 
can  be  no  harm  in  the  other  two  procedures  they  might  as  well  be  taken,  so 
long  as  it  is  convenient  in  any  given  case. 

Use  of  antiseptic  fluids.  There  is  still  a  distinct  superstition  in  favor  of 
the  use  of  some  antiseptic  fluid  for  washing  the  field  of  operation,  and  so  long 
as  the  fluid  employed  is  harmless  we  believe  that  we  are  justified  in  using  it. 
If  this  preparation  is  made  just  before  beginning  the  operation  it  will  suffice ; 
if  made  on  the  day  before  the  operation  the  surface  must  be  protected  against 
re-infection  during  the  interval,  which  can  be  done  by  applying  sterile  gauze 
or  cotton  to  the  surface  and  holding  it  in  place  by  means  of  a  carefully  applied 
bandage.  On  the  following  day  the  surface  is  once  more  washed  with  a 
piece  of  sterile  gauze  saturated  with  alcohol  and  is  then  ready  for  operation. 

Avoid  skin  irritation.  It  is  important  not  to  irritate  the  skin  by  the  violent 
use  of  a  stiff  brush  or  the  careless  use  of  the  razor,  and  care  should  be  taken 
to  have  the  razor  sterilized.  It  is  an  easy  matter  to  irritate  the  skin  during 
vigorous  or  violent  preparation  to  such  an  extent  that  the  micro-organisms 


GENERAL  SURGICAL  CONSIDERATIONS  49 

normally  contained  therein  will  be  forced  into  activity,  making  at  least  a 
slight  infection  certain  to  occur. 

It  is  much  better  simply  to  wash  the  field  of  operation  very  gently  with 
soap  and  warm  water  with  a  soft  piece  of  gauze  than  to  use  any  method, 
however  thorough  it  may  seem,  which  will  leave  the  skin  in  an  irritated 
condition. 

Sterile  towels  about  the  wound.  In  order  to  prevent  infection  of  the  field 
of  operation  from  any  of  the  adjacent  surfaces,  it  is  well  to  lay  four  sterile 
towels  around  the  part  and  hold  them  in  place  by  means  of  safety  pins,  or 
better  still  by  the  use  of  forceps  w^ith  sharp,  beetle-like  mouths  Avhich  will 
grasp  the  towels,  together  with  a  little  of  the  underlying  skin,  and  will  thus 
prevent  slipping  of  the  towels.  The  space  exposed  should  be  large  enough 
so  that  the  towels  need  not  be  shifted  during  the  operation,  because  such 
an  act  is  likely  to  cause  infection  by  carrying  micro-organisms  on  the  under 
surface  of  the  towel  from  adjacent  portions  to  the  field  of  operation.  During, 
the  operation  these  towels  should  be  left  in  place,  and  in  case  of  becoming 
soiled  they  should  be  covered  with  fresh  towels,  but  otherwise  they  should 
not  be  disturbed  or  removed.  Again,  when  the  operation  has  been  completed 
the  greatest  care  should  be  exercised  to  protect  the  wound  while  these  towels 
are  removed.  This  can  be  done  very  easily  by  placing  a  piece  of  moist,  aseptic 
gauze  over  the  entire  surface  of  the  wound  and  leaving  it  in  place  until  all 
the  necessary  disturbance  has  been  completed,  then  carefully  sponging  the 
surfaces  around  this  pad,  and  at  last  removing  the  pad  and  covering  the 
wound  with  proper  dressings. 

Avoid  infection  from  surrounding  parts.  During  the  operation  it  is  best 
to  handle  the  tissues  as  little  as  possible,  and  to  do  this  with  instruments 
as  much  as  may  be,  and  as  little  as  possible  with  the  hands,  and  never  to 
manipulate  the  patient's  skin  first  and  then  the  wound,  because  the  epidermis 
almost  always  contains  some  micro-organisms  which  might  be  transferred  to 
the  wound. 

A  practice  which  should  be  guarded  against  consists  in  first  sponging 
all  about  the  wound  and  finally  the  wound  itself.  If  the  skin  about  the  wound 
be  sponged  at  all,  the  same  sponge  should  not  be  used  in  or  upon  the  wound 
thereafter. 

Tincture  of  iodine  in  crushed  wounds.  Recently  a  method  of  disinfection 
of  the  field  of  operation  with  tincture  of  iodine  has  been  recommended  by 
Grossich,  which  has  the  excellent  qualities  of  being  simple,  convenient,  safe, 
efticient  and  generally  applicable.  The  method  has  been  further  developed 
and  perfected  by  Bogdan,  whose  plan  is  worthy  of  adoption,  especially  in 
cases  which  have  sustained  severe  crushing  injuries  in  which  the  method 
described  above  is  not  altogether  satisfactory  because  in  scrubbing  the  areas 
surrounding  the  wound  much  of  the  dirt  is  certaiii  to  drain  into  the  wound 
during  the  process  of  disinfection,  and  it  is  questionable  whether  the  harm 
which  will  be  done  hy  this  soiling  of  the  wound  is  not  greater  than  the  benefit 
derived  from  the  disinfection. 

Iodine  and  benzine.  Bogdan 's  method  consists  in  making  a  solution  of 
one  part  of  iodine  crystals  in  one  thousand  parts  of  benzine,  which  can  be 
readily  accomplished  by  adding  one  drachm  of  iodine  crystals  to  the  gallon 
of  benzine  or  one  gram  to  the  litre. 

The  entire  area  to  be  disinfected  is  carefully  shaved  dry  in  case  the 
portion  of  the  body  is  covered  with  a  perf^'^ntible  growth  of  hair.  It  is  then 
rubbed  off  carefully  with  pledgets  of  sterile  gauze  saturated  with  this  fluid. 
This  is  repeated  several  times,  the  disinfection  of  a  large  area  consuming 
not  more  than  two  or  three  minutes.  When  the  benzine  has  evaporated  the 
entire  surface  is  painted  repeatedly  with  tincture  of  iodine,  also  for  a  period 


50  GENERAL  SURGMCAL  CONSIDERATIONS 

of  about  two  minutes,  pledgets  of  sterile  cotton  being  used  for  this  purpose. 
As  soon  as  the  alcohol  contained  in  the  tincture  of  iodine  has  evaporated, 
leaving  the  area  perfectly  dry,  the  operation  may  begin.  This  method  has 
proven  most  satisfactory  and  may  be  employed  as  well  in  other  than  traumatic 
cases,  although  in  non-traumatic  cases  there  is  not  the  same  necessity  to  vary 
from  the  method  described  at  the  beginning  of  this  section. 

Caution  in  use.  In  these  cases  the  patient  should  be  given  a  thorough  soap 
and  warm  water  bath  on  the  day  before  the  operation,  and  the  operative  area 
should  be  soaped  and  shaved  and  again  washed  with  warm  water  in  order 
to  reduce  the  time  necessary  for  preparation  on  the  day  of  operation,  when 
the  remaining  steps  in  the  process  of  disinfection  described  above  should  be 
carried  out.  It  is  important  to  bear  in  mind  that  the  use  of  benzine  is 
extremely  dangerous  in  the  presence  of  gas-light  or  fire  of  any  kind,  conse- 
quently, in  preparing  the  field  of  operation,  quite  as  much  care  should  be 
taken  when  this  method  is  employed  as  when  ether  is  used. 

As  this  is  always  undertaken  by  thoroughly  trained  nurses  or  physicians, 
the  danger  is  not  really  very  great  if  their  attention  is  directed  to  this  factor. 

PREPARATION  OF  THE  SURGEON'S  HANDS 

What  has  been  said  concerning  the  preparation  of  the  field  of  operation 
applies  very  closely  to  the  care  of  the  operator's  hands  before  an  operation. 

Details  of  hand  disinfection.  The  important  point  is  to  make  sure  of 
careful,  thorough  washing  with  soap  and  sterile  water,  then  cleansing  the 
space  underneath  the  finger  nails,  then  washing  again,  first  with  a  moderately 
soft  brush  and  then  with  a  piece  of  gauze.  AVe  have  found  it  an  advantage 
to  wash  in  a  deep  basin  full  of  warm,  sterile  water,  keeping  the  hands  under 
water  while  scrubbing  with  the  brush  and  washing  with  the  gauze  pad,  and 
then  to  wash  in  sterile  running  water  after  the  hands  have  been  thoroughly 
scrubbed  underneath  the  soap  suds. 

Smooth  skin.  It  is  important  above  all  things  to  keep  the  skin  upon  the 
hands  smooth  and  soft,  and  not  covered  Avith  grooves  and  crevices.  If  the 
surgeon's  skin  is  smooth  it  is  much  easier  to  keep  the  hands  aseptic  than  if  it 
has  been  roughened  by  the  use  of  strong  antiseptic  solutions.  There  is  a 
great  difference  in  the  skin  of  the  hands  of  different  surgeons,  and  conse- 
quently it  is  wise  for  each  one  to  avoid  the  antiseptic  solution  which  happens 
to  be  harmful  in  his  case ;  and  if  all  solutions  have  the  same  effect,  it  is 
wise  simply  to  wash  with  soap  and  sterilized  water,  because  smooth  hands 
can  be  rendered  perfectly  safe  in  this  way,  while  rough  hands  cannot  be  made 
safe  by  the  additional  use  of  any  one  of  the  various  antiseptic  solutions  which 
have  been  recommended.  ^ 

Even  the  employment  of  certain  varieties  of  soap  has  a  ruinous  effect 
upon  the  hands  of  "some  surgeons,  but  with  them  it  is  always  possible  to 
determine  experimentally  what  variety  of  soap  has  this  harmful  effect  and  by 
changing  the  ingredients  so  as  to  neutralize  the  substance  which  gives  rise  to 
the  irritation  it  is  practically  always  possible  to  overcome  this  difficulty. 
Should  the  hands,  however,  become  roughened  notwithstanding  the  exercise  of 
all  of  these  precautions  this  can  usually  be  overcome  readily  by  systematically 
caring  for  the  hands  at  the  end  of  the  day  in  order  that  during  the  night's 
rest  the  skin  may  recover  from  the  dav's  irritation. 

To  overcome  roughness  of  the  hands.  The  hands  should  be  washed  before 
retiring  with  a  soft  cloth  in  a  deep  basin  filled  with  exceedingly  hot  water 
to  which  a  sufficient  amount  of  non-irritating  soap  has  been  added  to  make 
it  smooth,  or  in  case  all  soap  causes  irritation,  bran  may  be  added  to  the 
water.     The  water  should  be  just  as  hot  as  can  be  borne  and  the  washing 


GENEEAL  SURGICAL  CONSIDERATIONS  51 

should  be  continued  for  several  lAinutes  until  the  hands  are  thoroughly  hot. 
Then  they  should  be  plunged  into  cold  water,  that  is,  having  the  ordinary 
temperature  of  the  water  supply  in  most  cities.  After  a  minute  the  hands 
are  to  be  dried  and  anointed  with  lanoline  and  covered  for  the  night  with 
soft  chamois  skin  gloves.  In  most  instances  this  course  will  entirely  and 
speedily  overcome  the  rou^ghness  of  the  skin. 

In  our  own  practice  we  follow  the  washing  with  soap  and  water  by  the 
use  of  strong  alcohol,  and  then  a  solution  of  corrosive  sublimate,  one  to  two 
thousand. 

Avoid  pus.  In  hospital  practice  there  are  certain  other  precautions  which 
are  of  exceedingly  great  importance,  largely  in  the  way  of  prophylaxis,  which 
will  aid  ,greatly  in  securing  aseptic  conditions.  The  most  important  of  these 
is  to  keep  the  hands  out  of  pus.  In  dressing  suppurating  wounds  either 
forceps  or  rubber  gloves  should  be  used,  so  as  to  prevent  the  hands  from 
touching  pus.  Operations  should  be  performed  early  in  the  morning,  before 
any  one  connected  with  the  wounds  has  done  any  dressings.  Puddling  in  pus 
is  pernicious  practice.  This  fact  should  be  impressed  most  forcibly  upon 
every  one  connected  with  the  work. 

Aseptic  cases  should  always  be  operated  first,  and  later  those  containing 
pus.  In  operations  upon  suppurating  cases  rubber  gloves  are  used  at  the 
present  time,  but  in  former  years,  by  taking  the  precautions  indicated  above, 
practically  no  infections  took  place,  although  no  gloves  were  worn. 

Antiseptic  conscience.  The  same  precautions  should  be  taken  in  dressing 
the  wounds — ^no  suppurating  wounds  being  dressed  until  all  the  clean  wounds 
have  been  finished.  Every  evening  before  retiring  the  surgeon  and  all  the 
assistants  should  scrub  their  hands  with  the  same  care  that  is  employed  in 
disinfection  before  an  operation.  It  is  absolutely  necessary  for  every  one 
connected  with  surgical  work  to  develop  an  antiseptic  conscience,  because 
upon  this  depends  the  condition  of  the  wounds  rather  than  upon  any  special 
method. 

It  is  a  comparatively  easy  matter  to  secure  an  aseptic  condition  of  the 
hands  before  the  operation,  but  it  requires  great  vigilance  on  the  part  of 
every  one  associated  with  an  operation  to  maintain  this  condition  throughout 
the  procedure.  Unless  each  has  an  antiseptic  conscience  some  one  is  likely 
to  touch  something  which  is  not  surgically  clean  and  transfer  the  infectious 
material  with  his  hands  to  the  wound.  In  order  to  become  thoroughly  im- 
pressed with  the  ease  with  which  this  can  be  accomplished,  every  surgeon 
should  take  a  practical  course  in  a  bacteriological  laboratory  extending  over 
a  number  of  months,  because  the  same  carelessness  which  will  ruin  a  culture 
plate  may  cause  a  wound  infection,  and  one  really  cannot  fully  appreciate 
how  easily  this  occurs  until  after  having  had  the  experience  of  ruining  a  lot 
of  pure  cultures  in  bacteriological  experimentation, 

RUBBER  GLOVES 

If  a  surgeon  has  not  a  smooth,  pliable  skin,  or  if  for  any  reason  it  seems 
difficult  to  obtain  perfectly  clean  hands  by  washing,  or  if  he  has  recently 
touched  infected  wounds,  or  performed  autopsies,  or  dressed  suppurating 
cases,  it  is  well  to  protect  the  patient  to  be  operated  by  wearin,g  aseptic 
rubber  gloves. 

Objections.  It  should,  however,  be  borne  in  mind  that  the  surgeon  loses 
much  in  dexterity  in  this  way,  and  being  deprived  of  the  finer  sense  of  touch 
his  skill  is  quite  materially  impaired,  and  in  some  very  delicate  operations  this 
impairment  may  be  sufficient  to  deny  the  patient  the  slight  chance  he  had 
of  surviving  the  operation  or  receiving  the  best  results  therefrom.    Of  course, 


52  GENERAL  SURGICAL  CONSIDERATIONS 

this  would  apply  to  only  a  small  proportion  of  all  the  patients  operated  upon, 
but  it  is  large  enough  to  be  worth}^  of  consideration. 

It  is  quite  ditferent  with  the  hands  of  assistants  and  nurses  connected 
with  operations.  These  can  perform  the  less  delicate  duties  which  are  en- 
trusted to  them  as  well  with  gloves  as  with  bare  hands,  and  consequently 
the  additional  safety  which  comes  from  covering  their  hands  with  aseptic 
rubber  gloves  is  of  sufficient  importance  to  recommend  their  use. 

Details  of  use.  In  using  gloves  it  is  of  the  greatest  importance  to  disinfect 
the  hands  with  the  same  care  as  when  no  gloves  are  used,  because  a  glove 
may  tear  or  become  punctured  at  any  time  during  an  operation.  If  this  hap- 
pens the  glove  should  be  discarded  at  once,  as  a  torn  glove  is  necessarily  much 
more  dangerous  than  no  glove  at  all,  its  warmth  and  moisture  having  a  tend- 
ency to  loosen  the  epithelium  which  may  contain  pathogenic  micro-organisms. 

Confirm  necessity  for  gloves.  It  is  important  for  each  individual  surgeon 
to  determine  definitely  whether  or  not  it  is  possible  for  him  to  absolutely 
disinfect  his  hands.  This  can  be  done  easily  by  taking  scrapings  from  his 
fingers,  especially  from  portions  underneath  and  at  the  base  and  sides  of  the 
finger  nails.  If  a  surgeon's  hands  contain  micro-organisms  after  he  has  disin- 
fected them,  then  it  will  not  be  safe  for  him  to  operate  without  wearing 
rubber  gloves.  There  is  such  a  vast  difference  between  the  hands  of  different 
surgeons  that  a  rule  for  the  disinfection  of  the  hands  of  one  cannot  properly 
apply  to  others  without  confirmation  by  carefully'  carried  out  bacteriological 
tests. 

DISINFECTION  OF  INSTRUMENTS 

All  instruments,  except  knives,  should  be  boiled  for  half  an  hour  in  a 
solution  of  a  tablespoonful  of  baking  soda  to  the  quart  of  water  before  they 
are  put  away  after  operations,  and  again  before  they  are  used.  The  knives 
are  washed  carefully  with  pads  of  sterilized  cotton,  saturated  with  alcohol 
before  and  after  using. 

DISINFECTION  OF  SILK,  SILKWORM  GUT,  HORSE-HAIR,  DRAINAGE 

TUBES  AND  BRUSHES 

This  is  accomplished  by  boiling  in  water  for  one  hour,  and  preservation 
in  five  per  cent,  solution  of  carbolic  acid  in  Avater,  or  in  strong,  commercial 
alcohol,  until  used. 

Method  of  preparing  and  preserving  catgut.  Catgut  is  prepared  by  im- 
mersing in  sulphuric  ether  for  one  month,  then  for  one  month  in  strong,  com- 
mercial alcohol,  in  which  one  grain  of  corrosive  sublimate  to  the  ounce  has 
been  dissolved,  the  solution  being  renewed  once  during  this  time.  It  is  then 
preserved  indefinitely  in  a  solution  of  one  part  of  iodoform,  five  parts  of 
ether  and  fourteen  parts  of  strong,  commercial  alcohol.  In  this  solution  catgut 
may  be  preserved  with  perfect  safety  for  many  years  in  jars  which  prevent 
the  evaporation  of  the  ether.  The  loss  of  ether  from  the  jars  which  are  opened 
occasionally  for  the  removal  of  catgut  to  be  used  from  day  to  day  may  be 
made  good  by  adding  ether  occasionally  when  it  is  noticed  that  iodoform  is 
becoming  precipitated  at  the  bottom  of  the  vessel. 

It  is  not  necessary  to  be  accurate  concerning  the  amount  of  ether  replaced 
because  an  excess  in  no  way  injures  the  catgut.  The  entire  substance  of  the 
catgut  becomes  thoroughly  permeated  with  fine  crystals  of  iodoform,  which 
remain  in  the  suture  until  the  last  portion  of  catgut  fibre  has  been  absorbed. 
This  is  a  marked  advantage  over  catgut  saturated  with  iodine  in  which  no 
trace  of  this  antiseptic  can  be  found  two  days  after  the  introduction  of  the 


GENERAL  SURGICAL  CONSIDERATIONS  53 

buried  suture.  It  should  never  be  handled  by  any  one  except  the  surgeon 
and  the  chief  assistant.  This  catgut  will  last  seven  to  ten  days  in  tissues, 
according  to  the  size  used.  It  is  employed  in  all  ligatures,  both  in  the 
peritoneal  cavity  and  elsewhere,  and  for  all  buried  sutures  except  in  hernias 
and  in  the  suturing  of  bones.  For  these  purposes  a  chromicized  catgut  is 
employed,  which  lasts  from  fifteen  to  thirty  days,  according  to  size.  This  is 
prepared  after  the  following  formula:  The  catgut  is  immersed  in  ether  for 
one  month,  then  in  a  solution  prepared  in  the  following  manner : 

Chromicized  catgut. 

A.     Chromic  acid 1  part. 

Water  5  parts. 

(Carefully  dissolve.) 

B'.     Take  of  solution  A 1  part. 

Glycerine  5  parts. 

Take  solution  B;  and  soak  therein  catgut  for  forty-eight  to  ninety-six 
hours,  according  to  resistance  wanted.  Forty-eight  hours  will  resist  absorp- 
tion by  tissue  for  fifteen  days  •  ninetj^-six  hours  will  resist  for  thirty  days. 

C.  Take  catgut  out  of  solution  B,  rinse  quickly  in  sterilized  water  to 
free  it  from  solution  B,  stretch  and  rub  quickly  with  a  hard,  sterile  toAvel  to 
remove  any  of  the  solution  B  which  may  still  be  adhering  to  it,  wind  on 
rods,  or  slides  at  least  three  inches  in  length  and  preserve  indefinitely  in  the 
followin^g  solution: 

D.     Carbolic  acid,  95  per  cent 1  part. 

Glycerine  5  parts. 

The  catgut  may  remain  in  this  solution  for  many  months  without  depre- 
ciating in  quality,  or  it  may  be  kept  for  an  indefinite  period  of  time  in  the 
same  solution  as  the  ordinary  catgut,  composed  of: 

Iodoform   1  part. 

Ether 5  parts. 

Strong  alcohol 14  parts. 

The  jar  containing  the  ether  in  which  the  catgut  is  kept  for  one  month 
should  be  filled  only  about  one-half  with  the  loose  coils  of  catgut  and  then 
it  should  be  filled  with  ether ;  it  should  be  closed  air  tight  and  should  be  picked 
up  every  day  or  two  and  shaken  in  an  inverted  position  in  order  to  wash 
off  any  substance  which  may  accumulate  upon  the  surface  of  the  coils.  At  the 
end  of  two  weeks  the  ether  should  be  removed  and  fresh  ether  substituted. 

The  same  precautions  should  be  taken  with  the  solution  of  corrosive 
sublimate  in  alcohol. 

It  is  especially  important  not  to  wind  the  catgut  tightly  before  placing 
it  in  these  solutions,  because  this  may  prevent  the  solutions  from  penetrating 
all  parts  of  the  material. 

One  precaution  is  necessary  in  the  employment  of  catgut  which  has  been 
prepared  in  this  manner;  it  must  not  be  placed  in  water  before  it  is  used  at 
the  time  of  the  operation. 

It  seems  that  the  iodine  which  is  absorbed  by  the  catgut  in  the  iodoform- 
ether-alcohol  solution  makes  it  slightly  antiseptic,  which  is  probably  an 
advantage. 

Upon  splitting  a  piece  of  catgut  which  has  been  preserved  in  this  fluid 


54  GENERAL  SURGICAL  CONSIDERATIONS 

and  permitting  it  to  dry  it  will  be  found  that  the  entire  substance  is  permeated 
with  fine  crj^stals  of  iodoform  which  will  be  absorbed  no  more  rapidly  than 
the  catgut  itself,  thus  making  the  latter  slightly  antiseptic  until  it  is  entirely 
absorbed. 

This  seems  to  be  of  importance  especially  in  the  use  of  chromic  gut  because 
of  the  length  of  time  it  normally  remains  in  the  tissues. 

These  two  methods  are  so  simple  that  they  can  be  carried  out  as  well 
in  the  simplest  office  of  the  country  practitioner  as  in  the  laboratory  of  a 
well-organized  hospital. 

Experience  results.  We  have  personally  used  catgut  prepared  in  this  man- 
ner in  more  than  twenty-five  thousand  operations,  and  the  fact  that  we  have 
adhered  to  this  method  of  preparation,  while  we  have  changed  almost  every 
other  detail  in  antiseptic  technique  in  the  meantime,  shows  that  this  very 
simple  method  must  be  satisfactory. 

Catgnt  infection.  Observations  have  convinced  us  that  what  is  ordinarily 
known  and  feared  as  catgut  infection  is  quite  unnecessary  and  that  it  depends 
upon  one  or  more  of  five  conditions  which  can  easily  be  eliminated,  viz.:  1, 
Commercial  catgut  which  may  not  be  reliable;  2,  Catgut  that  has  been  sat- 
urated with  antiseptic  substances  which  cause  a  necrosis  of  the  tissues  included 
in  the  suture  or  ligature ;  3,  Pressure  necrosis  due  to  tying  the  stitches  too 
tightly;  4,  Infection  of  the  catgut  by  careless  manipulation  by  the  surgeon 
or  his  assistants,  the  suture  or  ligature  being  permitted  to  touch  objects  not 
sterile;  5,  Infection  of  the  catgut  by  the  septic  hands  of  the  surgeon  or  his 
assistants. 

PRESSURE  NECROSIS 

Although  drawing  sutures  or  ligatures  tightly  enough  to  cause  pressure 
necrosis  cannot  produce  infection  by  itself,  this  is,  nevertheless,  a  very  com- 
mon, if  not  the  most  common,  cause  of  what  is  termed  "catgut  infection," 
inasmuch  as  this  furnishes  a  very  favorable  culture  medium  for  any  accidental 
infection  which  may  occur  during  the  operation  and  which  would  not  develop 
into  suppuration  were  not  the  tissues  impaired  by  the  constriction  due  to  the 
undue  tension  placed  upon  the  stitches  or  ligatures. 

It  has  seemed  to  us  that  much  of  the  improvement  in  aseptic  results  which 
many  surgeons  have  attributed  in  their  practice  to  the  use  of  rubber  gloves 
must  be  due  to  the  fact  that  the  wearing  of  gloves  which  have  an  exceedingly 
smooth  surface  has  prevented  them  from  tying  their  stitches  and  ligatures 
too  tightly  and  that  this  explains  the  decrease  in  the  amount  of  catgut  infection 
in  their  experience. 

This  point  is  so  important  that  we  shall  refer  to  it  again  in  connection 
with  the  various  operations  in  which  its  neglect  is  especially  likely  to  cause 
mischief. 

Importance  of  safe  catgut.  We  have  spoken  at  length  concerning  catgut, 
because  if  properly  prepared  and  used  it  is  certainly  an  ideal  suture  and 
ligature  material,  and  it  is  important  to  have  this  material  so  that  it  can  be 
invariably  relied  upon.  Undoubtedly  some  manufactures  furnish  catgut  in 
a  condition  in  which  it  can  always  be  depended  upon,  but  it  is  difficult  to 
ascertain  which  of  these  firms  are  reliable,  consequently  it  is  best  for  each 
surgeon  to  prepare  his  own  material.  In  large  hospitals  this  can,  of  course, 
be  delegated  to  a  dependable  person  who  is  permanently  employed  and  who 
fully  comprehends  the  importance  of  his  task.  It  is  not  well  to  assign  assist- 
ants who  frequently  change  their  service  to  undertake  this  work,  because"  then 
it  is  impossible  for  the  surgeon  to  fix  the  responsibility. 


GENERAL  SUEGICAL  CONSIDERATIONS  55 

IODINE  CATGUT 

Catgut  impregnated  with  iodine  has  been  in  use  for  a  number  of  years 
and  has  given  excellent  satisfaction  to  those  who  have  employed  it  constantly. 
The  presence  of  this  antiseptic  material  seems  to  increase  the  safety  of  the 
suture  or  ligature  substance  because  it  may  serve  to  destroy  any  micro-organ- 
isms which  may  have  been  introduced  accidentally  during  the  operation. 
However,  the  especial  value  of  this  method  lies  in  its  simplicity  and  in  the 
fact  that  the  tensile  strength  of  the  catgut  is  but  slightly  impaired  by  the 
process  of  preparation.  The  fact  that  the  iodine  is  entirely  absorbed  long 
before  the  catgut  disappears  makes  this  suture  material  slightly  less  desir- 
able to  use  than  that  prepared  by  the  method  described  above.  It  is,  however, 
possible  to  preserve  this  suture  material  indefinitely  in  the  same  iodoform- 
ether-alcohol  mixture  that  we  use  for  the  cut(gut  already  described  if  the 
catgut  is  first  carefully  prepared  by  the  iodine  method,  especially  if  the  most 
excellent  process  invented  by  Willard  Bartlett,  of  St.  Louis,  is  chosen. 

Willard  Bartlett  method  of  preparing.  In  order  to  secure  uniformly  satis- 
factory results  it  is  important  to  carry  out  the  various  steps  laid  down  in  the 
following  description  of  the  method  with  the  utmost  accuracy,  because  if  any 
change  is  made  in  these  steps  the  catgut  is  likely  to  become  somewhat  hard 
or  brittle.  It  is  also  important  to  remember  that  the  method  must  never  be 
attempted  in  wet  weather  or  in  a  room  containing  steam  or  moisture. 

"1.  The  strands  are  cut  into  convenient  lengths,  say  thirty  inches,  and 
made  into  little  coils  about  as  large  as  a  silver  quarter.  These  coils  in  any 
desired  number  are  then  strung  like  beads  onto  a  thread  so  that  the  whole 
quantity  can  be  conveniently  handled  by  simply  grasping  the  thread. 

"2.  The  strings  of  catgut  coils  are  dried  for  four  hours  at  the  following 
temperatures :  160,  180,  200,  220  degrees,  one  hour  each,  the  changes  in  tem- 
perature being  gradually  accomplished. 

"3.  The  catgut  is  placed  in  liquid  albolene,  where  it  is  allowed  to  remain 
until  perfectly  'clear,'  in  the  sense  that  the  term  is  used  in  the  preparation  of 
histological  specimens.  This  is  usually  accomplished  in  a  few  hours,  though 
it  has  been  my  custom  to  allow  the  gut  to  remain  in  the  oil  over  night. 

"4.  The  vessel  containing  the  oil  is  placed  upon  a  sand  bath  and  the 
temperature  raised  during  one  hour  to  320  degrees  F.,  which  temperature  is 
maintained  for  a  second  hour. 

"5.  By  seizing  the  thread  with  a  sterile  forcep  the  catgut  is  lifted  out  of 
the  oil  and  placed  in  a  mixture  of  iodine  crystals  one  part  in  Columbian 
spirits  (deodorized  methyl  alcohol)  one  thousand  parts.  In  this  fluid  it  is 
stored  permanently,  and  is  ready  for  use  in  twenty-four  hours ;  the  thread  is 
then  cut  and  withdrawn. 

"It  seems  to  me  important  that  the  gut  should  be  thoroughly  'cleared' 
before  the  oil  is  heated,  in  order  that  we  may  thus  be  certain  that  the  tem- 
perature of  the  center  of  the  strand  becomes  as  high  as  that  of  the  oil  outside. 
It  may  be  noted  further  that  I  do  not  remove  the  oil  from  the  gut  before 
placing  it  in  the  storing  solution.  This  is  done  purposely,  since  catgut  which 
is  perfectly  free  from  oil  is  so  very  sensitive  to  the  action  of  water  that  it 
readily  untwists  and  becomes  tangled  after  it  is  used  in  a  wound  but  a  few 
moments.  This  storin,g  fluid  simply  takes  off  enough  oil  from  the  exterior 
of  the  strand  so  that  it  is  not  too  slippery  for  use,  and  the  albolene  being  a 
bland,  non-irritating  substance,  there  is  no  reason  wliy  it  cannot  be  safely 
left  in  the  gut.  The  iodine  rapidly  permeates  the  strand;  the  same  will  be 
found  stained  black  after  a  few  hours,  and  consequently  the  surgeon  will 
have  the  assurance  that  he  is  introducing  an  antiseptic  as  well  as  a  thoroughly 
sterile  suture  material. 


56  GENERAL  SURGICAL  CONSIDERATIONS 

"As  far  as  the  tensile  strength  and  pliability  of  the  finished  product  are 
concerned,  I  may  state  that  this  leaves  nothing  to  be  desired.  1  have  made 
a  large  number  of  breaking  tests,  and  have  found  no  other  heat  method  to 
produce  a  stronger  strand.  Catgut  treated  in  this  way  lasts  in  the  tissues 
about  as  long  as  the  same  sized  strand  treated  by  most  of  the  other  methods 
in  vogue  at  the  present  time,  the  No.  2  gut  generally  requiring  about  one 
week  for  its  absorption.  I  have  not  found  that  the  material  so  treated  deteri- 
orates at  all  with  age,  neither  as  far  as  strength  or  sterility  is  concerned.  In 
fact,  I  have  recently  had  a  large  number  of  strands  bacteriologically  exam- 
ined from  a  jar  which  had  been  frequently  opened  during  the  past  year,  and 
have  yet  to  find  the  first  one  infected  or  in  any  other  way  undesirable  for  use 
in  surgery." 

All  material  that  can  be  boiled  for  one  hour  is  perfectly  safe  to  use  for 
sutures  which  are  to  be  removed  because  such  boiling  insures  the  sterility  of 
the  material  at  the  time  it  is  placed  in  the  wound,  provided  it  is  not  infected 
during  its  introduction.  Of  course,  it  may  be  infected  while  passing  through 
the  skin  or  from  micro-organisms  which  progress  along  the  suture  between 
the  time  of  its  insertion  and  the  time  of  its  removal,  or  from  micro-organisms 
existing  in  the  blood  which  may  become  located  at  this  point  of  traumatism, 
but  if  the  stitches  are  not  tied  too  tightly  this  result  is  not  likely  to  occur, 
because  there  will  not  be  a  favorable  culture  medium  along  the  stitch  unless 
prepared  by  pressure  necrosis. 

TANNED  CATGUT 

Ssobolew  method.  The  catgut  is  wound  loosely  upon  glass  slides.  It  is 
immersed  for  twenty-four  hours  in  extract  of  quebracho  to  which  one  per 
cent,  of  phenol  has  been  added.  It  is  then  washed  in  sterile  water  and 
immersed  for  twenty-four  hours  in  an  aqueous  solution  of  formaldehyde  ac- 
tually 4  per  cent,  but  10  per  cent,  of  commercial  formalin  in  water.  It  is  then 
washed  for  twenty-four  hours  in  running  water,  then  boiled  for  fifteen  minutes 
in  water  and  while  still  hot  it  is  immersed  in  a  mixture  of  96  per  cent,  strong 
commercial  alcohol  91  parts,  glj^cerine  5  parts  and  phenol  4  parts.  In  this 
solution  it  may  be  preserved  indefinitely,  being  washed  in  water  to  remove 
the  phenol  before  usin^g. 

It  may  also  be  placed  in  this  mixture  for  a  time  and  then  preserved  indefi- 
nitely in  the  iodoform-ether-alcohol  mixture  previously  described. 

The  finest  catgut  will  absorb  in  not  less  than  two  weeks,  and  the  larger 
sizes  in  from  two  to  six  weeks. 

Ligature  material  boiled  in  paraffine.  Of  the  boilable  materials  for  suturing 
silk,  linen,  either  plain  or  covered  with  celluloid,  also  these  materials  boiled 
in  parafiine  at  a  temperature  not  to  exceed  150  degrees  C.  or  in  10  per  cent, 
of  iodoform  in  paraffine,  may  be  employed  with  perfect  safety  provided  the 
sutures  extend  through  the  surface  so  that  they  may  be  removed  or  that  only 
the  very  fine  threads  are  used  in  case  of  buried  sutures  or  ligatures. 

Hyper-tension  favors  suppuration.  Many  surgeons  complain  of  suppura- 
tion when  using  catgut  for  ligatures  and  buried  sutures  who  are  much  more 
fortunate  when  they  use  for  these  purposes  only  the  finest  silk  or  linen.  We 
are  convinced  of  the  fact  that  this  is  due  to  the  circumstance  that  when 
using  catgut  an  amount  of  tension  is  applied  in  tying  the  sutures  or  ligatures 
which  would  break  the  fine  silk  or  linen,  and  consequently  when  using  the 
latter  material  these  surgeons  cannot  cause  the  same  amount  of  pressure 
necrosis  as  they  can  when  using  the  much  heavier  catgut. 


GENERAL  SURGICAL  CONSIDERATIONS  57 

DISINFECTION  OF  DRESSINGS 

All  dressings  should  be  disinfected  in  a  steam  sterilizer,  two  hours  being 
given  for  steaming  and  one  hour  for  drying.  The  same  treatment  is  given 
to  aprons,  sheets  and  towels. 

One-fourth  of  this  time  is  quite  sufficient  to  make  surgical  dressings  abso- 
lutely sterile,  as  has  been  demonstrated  by  hundreds  of  experiments,  and  if 
this  work  is  in  the  personal  care  of  one  who  has  been  entrusted  with  it  for 
a  long  period  the  time  may  be  reduced  accordingly^  but  if  it  is  assigned  to 
the  nurses  in  general,  it  is  better  to  allow  more  time  than  is  actually  required, 
as  no  harm  is  done  to  the  dressing  material  by  exposing  it  the  additional  time 
to  the  superheated  steam  in  the  sterilizer. 

The  dressings  should  be  arranged  in  packages  and  placed  in  heavy  muslin 
bags  or  folded  in  thick  towels  securely  pinned  so  that  the  contents  will  not 
be  contaminated  when  these  packages  are  handled. 

Each  package  should  be  labeled  by  writing  the  name  of  the  contents  on 
the  covering  with  lead  pencil,  or  if  permanent  bags  are  always  used  for  the 
same  contents  these  may  be  permanently  labeled  with  indelible  ink  in  order 
that  it  may  never  be  necessary  to  examine  the  contents  to  find  what  may  be 
wanted. 

All  abdominal  pads  should  be  cut  in  three  or  four  lengths  only.  A  large 
number  of  sizes  usually  complicates  the  counting  during  the  operation.  Each 
size  should  have  a  definite,  uniform  length. 

We  have  found  that  the  most  satisfactory  method  of  preventing  the  loss 
of  pads  in  the  abdomen  is  that  of  counting.  All  such  pads  are  placed  in 
packages  containing  one  dozen.  The  pads  which  have  been  used  during  the 
operation  are  collected  by  a  nurse  who  is  responsible  for  this  dutj^,  and  she 
places  them  in  lots  of  one  dozen  each.  At  the  end  of  the  operation,  the  pads 
she  has  left,  plus  those  on  the  operating  table,  plus  those  still  in  possession  of 
the  surgical  nurse,  should  total  twelve,  or  a  multiple  of  twelve.  In  this  way 
the  count  is  constantly  kept  up. 

It  is  also  well  to  have  all  of  the  pads  cut  by  measure  by  one  individual 
nurse  for  a  number  of  months.  No  one,  except  the  surgeon  and  the  nurse  at 
the  head  of  the  surgical  department,  should  know  the  exact  length  of  each 
type  of  pads,  of  which  a  record  should  be  kept  giving  the  period  during 
which  these  sizes  were  in  use.  In  at  least  one  instance  in  a  malpractice  suit, 
in  which  it  was  claimed  that  a  strip  of  gauze  twenty-five  feet  lon,g  was  found 
in  the  patient  several  months  after  operation,  the  fact  that  no  pads  had  been 
used  at  that  time  which  were  longer  than  nine  feet,  proved  that  the  pad 
which  was  claimed  to  have  been  found,  had  been  fraudulently  inserted  by 
some  one  who  had  planned  to  extort  money  from  the  surgeon. 

DISINFECTION   OF  EVERYTHING   COMING  DIRECTLY  IN   CONTACT 

WITH  WOUNDS 

The  basins,  instrument  pans,  jars  for  dressings,  etc.,  are  to  be  boiled  in 
soda  and  water  for  one  hour,  then  wrapped  up  in  sterilized  sheets  until  used. 
The  tables  should  be  scrubbed  with  soap  and  water  and  then  with  1  to  1,000 
corrosive  sublimate  in  water,  and  have  them  always  covered  with  a  double 
sterilized  sheet  when  in  use.  The  ordinary  pads  of  cotton  and  of  gauze,  ster- 
ilized in  a  steam  sterilizer,  are  used  in  place  of  sponges  in  all  operations. 

A  one  per  cent,  solution  of  formaldehyde  in  water  is  very  satisfactory  for 
washing  all  of  these  apparati  and  especially  for  the  purpose  of  disinfecting 
bath-tubs  and  stationary  wash-basins.  The  latter  should,  however,  never  be 
used  in  operating  rooms  where  all  the  basins  for  washing  the  hands  of  the 


58  GENERAL  SURGICAL  CONSIDERATIONS 

surgeon,  assistants  and  nurses  are  so  arranged  that  they  can  be  removed  from 
the  stands  and  boiled,  a  sufficient  number  of  these  removable  basins  being 
kept  ready  so  that  they  may  be  replaced  by  sterile  ones  between  operations. 
The  nurses  who  scrub  these  various  utensils  with  these  strong  antiseptic 
solutions  should  invariably  wear  thick  rubber  gloves  while  performing  this 
portion  of  their  duties,  because  the  skin  of  their  hands  will  otherwise  become 
roughened  and  thus  constitute  a  danger  to  the  service  owing  to  the  ease  with 
which  infectious  material  may  become  lodged  in  the  crevices  formed. 

DRAINAGE 

When  used.  Drainage  is  always  used  in  very  large,  clean  wounds,  such 
as  breast  amputations  with  removal  of  the  pectoralis  major  and  minor  muscles 
and  axillary  glands,  also  in  thigh  amputations,  usually  only  for  three  or  four 
days ;  never  in  herniotomies  except  for  strangulated  hernia  complicated  with 
gangrene,  nor  in  small,  clean  wounds. 

Rubber  tubing.  The  ordinary  perforated  rubber  tube  is  employed.  It  is 
always  used  in  wounds  that  are  primarily  septic ;  and  whenever  there  is  any 
doubt  as  to  the  aseptic  condition  of  a  wound  we  drain.  AVe  have  found  the 
use  of  an  ordinary  leather  punch  very  convenient  for  making  the  necessary 
perforations  in  rubber  tubing.  In  many  instances,  rubber  tubes  split  longitud- 
inally^ throughout  seem  to  be  especially  useful. 

Glass  tubes.  In  wounds  in  which  the  pressure  from  the  dressing  would  be 
likely  to  cause  collapse  of  a  rubber  drainage  tube,  as,  for  instance,  in  opera- 
tions for  the  removal  of  goitre,  the  small  perforated  glass  tubes  introduced 
by  Kocher  are  most  satisfactory.  Thej^  may  be  kept  on  hand  in  various  forms 
both  straight  and  curved,  and  in  various  lengths  and  sizes,  in  order  that  they 
may  suit  the  conditions  found  in  an}^  given  case. 

In  the  abdominal  cavity  we  use  glass  tubes,  closed  at  the  end,  having  a 
number  of  small  perforations  toward  the  lower  end.  A  strand  of  gauze  is 
carried  to  the  bottom  of  the  tube  to  act  as  a  capillary  drain.  A  piece  of  iodo- 
form or  formidin  gauze,  folded  about  four  double,  is  placed  over  the  glass 
tube,  which  is  then,  with  this  covering,  carried  down  to  the  point  to  be 
drained.  In  operations  upon  the  pelvic  organs  it  is  carried  to  the  bottom  of 
the  cul-de-sac  of  Douglas. 

Glass  and  rubber  drainage  tubes  are  usually  removed  in  from  two  to  five 
days  after  an  operation.  In  this  length  of  time  drainage  will  have  been 
established  and  danger  of  pressure-necrosis  is  avoided. 

CIGARETTE  DRAIN 

In  order  to  prevent  the  formation  of  adhesions  between  portions  of  the 
intestines  which  come  in  contact  with  the  gauze  covering  the  glass  drain  the 
latter  is  surrounded  on  the  side  directed  toward  the  intestines  or  stomach  by 
a  row  of  so-called  cigarette  drains,  introduced  by  Robert  Morris.  These 
drains  are  made  by  placing  one  or  more  layers  of  gauze  upon  a  piece  of  gutta 
percha  tissue  so  that  the  former  is  two  or  three  cm.  longer  and  five  or  more 
cm.  narrower  than  the  latter.  The  gauze  is  then  rolled  up  inside  of  the  tissue 
so  that  it  will  be  entirely  covered  by  the  latter  and  so  that  its  ends  will  pro- 
ject slightly  from  either  extremity,  giving  the  drain  the  appearance  of  a 
cigarette  varying  in  size  according  to  the  area  to  be  drained.  Thus  a  capil- 
lary drain  is  constructed  which  is  surrounded  by  a  non-irritating,  soft,  pliable 
covering  of  gutta  percha  tissue. 

A  similar  drain  can  be  made  by  splitting  a  large  soft  rubber  drainage  tube 
longitudinally  and  placing  a  strand  of  gauze  within  its  lumen. 


GENERAL  SURGICAL  CONSIDERATIONS  59 

In  order  to  prevent  adhesions  and  also  to  facilitate  drainage,  flat  tapes  of 
sterile  gauze  saturated  with  vaseline  oil  may  be  used. 

The  gutta  percha  tissue  may  be  disinfected  by  washing  in  one  to  one  thou- 
sand of  corrosive  sublimate  in  water  and  by  exposing  the  moist  sheets  to  the 
fumes  of  formaldehyde.  The  material  will  not  bear  disinfection  by  boiling 
or  by  exposure  to  steam. 

IRRIGATION 

"We  practically  never  use  irrigation  during  operations,  either  in  the  ab- 
dominal cavity  or  elsewhere. 

[During  the  early  days  of  my  surgical  work,  as  an  assistant,  I  observed 
that  wounds  in  abdominal  sections  healed  more  smoothly  than  in  other  opera- 
tions, and  the  only  real  difference  in  the  treatment  observable  was  the  fact 
that  no  irrigation  was  used  in  connection  with  the  former,  while  it  was 
invariably  employed  in  the  others.  I  consequently  applied  the  same  plan  of 
treatment  to  all  wounds  as  early  as  1889,  and  have  since  constantly  operated 
dry  in  clean  cases,  and,  since  a  number  of  years,  also  in  cases  containing  pus. 
I  have  treated  wounds  in  circumscribed  tuberculous  lesions  by  applying 
strong  compound  tincture  of  iodine,  and  then  sponging  the  area  with  moist 
gauze  sponges  before  tamponing  with  iodoform  gauze  or  before  closing  with 
sutures.  These  wounds  have  progressed  well,  but  I  do  not  feel  convinced  that 
the  iodine  has  been  responsible  for  this  fact.  Very  recently  in  tuberculosis  of 
the  joints  I  have  applied  strong  carbolic  acid  to  the  surfaces  of  the  bones  for 
two  minutes,  and  have  then  washed  these  parts  thoroughly  with  strong  alcohol 
until  all  of  the  carbolic  acid  seemed  removed.  I  am  convinced  that  irrigation 
is  rarely  of  any  real  benefit  and  that  it  is  frequently  harmful  in  carrying 
infectious  material  to  portions  which  might  otherwise  have  escaped  infection. 
— Ochsner.] 

Primary  union  depends  upon  thorough  system.  Our  observations  have 
convinced  us  that  it  is  an  exceedingly  simple  matter  to  obtain  primary  union 
almost  invariably  if  one  has  a  reasonable  system,  i.  e.,  a  system  which  keeps 
the  attention  of  operator,  assistants  and  nurses  constantly  on  guard  to  pre- 
vent accidental  contamination. 

Whenever  some  new  method  is  on  trial  in  any  hospital  or  clinic  every  one 
is  interested  and,  consequently,  accidental  contamination  is  not  likely  to 
occur.  It  is  for  this  reason  that  the  various  new  methods  are  so  successful  in 
the  hands  of  their  originators. 

Theory  vs.  practice  in  surgical  methods.  A  close  observation  of  antiseptic 
and  aseptic  surgery  from  its  beginning  to  the  present  time  has  led  us  to  the 
conclusion  that  there  is  a  vast  amount  of  difference  and  contradiction  between 
the  theories,  which  are  at  present  generally  accepted,  and  the  practical  results. 
So  far  as  a  scientific  study  of  the  subject  is  concerned,  both  the  theoretical 
considerations,  which  are  mainly  based  upon  scientific  experiments,  and  the 
practical  observations  upon  wounds,  must  be  borne  in  mind.  So  far  as  the 
welfare  of  any  particular  patient,  or  any  group  of  patients,  is  concerned,  only 
those  facts  which  practice  has  shown  to  be  of  importance  in  order  to  secure 
primary  union  should  be  considered,  because  they  will  bear  directly  upon  the 
welfare  of  a  human  being  who  has  entrusted  himself  to  our  care.  The  follow- 
ing conclusions  will  serve  to  express  our  position  upon  this  subject. 

1.  (a)  Theoretically  it  is  almost  impossible  to  absolutely  disinfect  the  skin 
of  the  patient  and  the  hands  of  the  operator. 

(b)  Practically  it  is  one  of  the  easiest  and  simplest  tasks  to  obtain  a  degree 
of  surgical  cleanliness  that  will  insure  primary  wound-healing. 


60  GEXEEAL  SURGICAL  CONSIDERATIONS 

2.  (a;  Theoretically,  strong  chemical  disinfectants  are  indicated  for  the 
purpose  of  disinfecting  the  hands. 

(b  '  Practically,  careful  washing  with  the  mildest,  viz.,  soap  and  water 
and  alcohol,  is  absolutely  sufficient  and  very  much  safer  for  the  patient,  be- 
cause hands  roughened  by  the  use  of  strong  antiseptics  are  much  more  prone 
to  become  hopelessly  septic  than  hands  which  are  covered  with  smooth, 
healthy  skin. 

3.  (a J  Theoretically,  it  is  extremely  simple  to  keep  the  hands  aseptic  after 
they  have  been  rendered  so. 

(bj  Practically,  there  is  no  more  difficult  task  in  any  clinic,  or  during  an 
operation  in  a  private  house,  than  to  keep  all  interested  hands  clean  after 
they  have  been  disinfected. 

4.  (a ;  Theoretically,  sutures  passing  through  the  skin  and  the  deep  tissues 
underneath  are  a  menace  to  the  patient,  because  they  form  a  direct  commu- 
nication between  the  skin,  containing  staphylococci,  and  the  deep  tissues 
which  are  primarily  sterile. 

(hj  Practically,  these  stitches  never  cause  an  infection,  unless  drawn  too 
tightly,  in  which  case  the  resulting  pressure-necrosis  is  the  cause  of  the 
mischief  as  it  furnishes  these  micro-organisms  dead  tissue  to  thrive  upon. 

5.  (aj  Theoretically,  catgut  sutures  and  ligatures  are  objectionable, 

(b)  Practically,  if  applied  properly  by  a  clean  surgeon  with  clean  assist- 
ants, and  not  tied  too  tightly,  they  are  absolutely  satisfactory  and  not 
objectionable. 

6.  (a '  Theoretically,  it  is  as  safe  to  operate  upon  clean  cases  after  dress- 
ing suppurating  wounds  as  at  any  other  time. 

Chj  Practically,  surgeons  who  follow  this  practice  always  have  a  great 
amount  of  wound  infection,  on  account  of  accidental  contamination  of  some- 
thing coming  in  contact  with  the  wounds. 

Conditions  requisite  to  asepsis.  In  order  to  have  wounds  heal  without 
suppuration  we  believe  the  following  conditions  should  be  enforced : 

1.  The  surgeon,  his  assistants  and  nurses,  must  be  habitually  clean,  and 
the  skin  of  their  hands  must  be  free  from  irritation  and  roughness. 

2.  Their  attention  should  constantly  be  directed  toward  the  prevention  of 
accidental  infection. 

3.  The  surgeon  and  his  assistants  should  be  careful  not  to  breathe  or  speak 
into  the  wounds. 

4.  Tissues  should  not  be  exposed  to  imnecessary  traumatism. 

5.  Sutures  should  not  be  tied  tightly  enough  to  cause  pressure-necrosis. 

6.  A  reasonable  system  should  be  employed  so  that  every  one  concerned 
can  assist  intelligently  in  preventing  infection. 

THE  OPERATING  ROOM 

Direction  of  Hght.  The  hospitals  of  this  country  are  all  supplied  with 
suitable  operating  rooms,  with  the  one  criticism  that  many  of  them  are  badly- 
lighted.  The  light  should  come  from  the  north  and  from  sky-lights  facing 
north,  in  order  to  have  uniform  brightness  and  not  direct  sun-light,  and  to 
avoid  the  overwhelming  heat  which  is  caused  by  sky-lights  facing  the  sun. 

In  great  cities  operating-rooms  should  be  on  the  highest  floor  in  high  build- 
ings, because  the  air  contains  much  less  street  dust  in  the  upper  stories  of  a 
high  building  than  near  the  ground,  and  consequently  less  infectious  material 
is  likely  to  accumulate  in  places  from  which  an  infection  can  be  carried  to 
the  wounds. 

Advantages  of  the  hospital.  Operations  are  always  best  performed  in 
hospitals,  and  every  city  and  town  in  the  country  should  support  a  hospital 


aENERAL  SURGICAL  CONSIDERATIONS  61 

suitable  in  size  to  the  commimity  tributary  to  it.  This  can  be  established  and 
maintained  at  a  small  cost  and  is  of  great  benefit  to  the  community  because 
it  supplies  a  means  of  proper  treatment  for  eases  which  must  otherwise  be 
satisfied  with  generally  very  inefficient  care.  Moreover,  it  serves  as  the  most 
powerful  incentive  for  the  entire  medical  profession  in  the  community  in 
which  it  is  maintained  because  it  furnishes  a  reasonable  opportunity  for 
advancement. 

The  leading  consideration  in  the  private  home.  But  many  operations  must 
for  the  present  be  performed  in  the  homes  of  patients  and  here  it  might  be 
considered  more  difficult  to  arrange  an  operating  room.  As  a  matter  of  fact 
there  is  but  one  point  to  be  borne  in  mind  in  the  arrangement  of  a  room  for 
operating,  namely,  infection,  and  that  no  wound  infection  is  to  be  considered 
except  from  contact.  Not  that  infection  from  the  air  is  absolutely  impossible 
theoretically,  but  that,  practically,  a  wound  remains  aseptic  unless  infectious 
material  has  been  placed  in  it  by  dirty  hands,  dirty  instruments,  appliances 
or  sponges,  ligatures,  sutures  or  dressings,  unless  the  infectious  material  ex- 
isted in  the  patient's  body  at  the  time  of  operation.  Of  course  the  operator 
could  infect  a  wound  by  breathing  or  speaking  into  it  if  his  pharynx  or  air 
passages  were  infected. 

Universal  cleanliness  required.  But  in  any  case  in  which  a  clean  surgeon 
with  clean  assistants  and  clean  appliances  operates  upon  a  clean  patient,  it 
can  be  expected  with  a  fair  degree  of  certainty  that  the  wound  Avill  remain 
aseptic,  no  matter  what  the  surroundings  may  be.  On  the  other  hand,  the 
most  perfectly  appointed  operating-room  cannot  prevent  a  septic  surgeon 
from  having  his  wounds  in  clean  patients  suppurate. 

Details  of  preparation  in  the  private  home.  It  is  best,  Avhen  compelled  to 
operate  in  a  dwelling-house,  to  choose  the  lightest  room,  to  make  as  little  dis- 
turbance as  possible,  and  thus  avoid  stirring  up  dust,  to  arrange  everything 
very  simply  and  to  utilize  the  least  possible  amount  of  furniture.  An  ordinary 
extension  table  will  serve  admirably  for  an  operating  table.  Let  it  be  drawn 
out  so  that  there  is  a  space  of  three  feet  in  the  center  and  then  two  of  the 
boards  may  be  placed  lengthwise  so  as  to  leave  a  notch  on  one  side  for  the 
surgeon  to  stand  and  on  the  other  side  for  his  assistant.  A  quilt  or  blanket 
may  be  folded  upon  itself  three  or  four  times  and  placed  lengthwise  upon  the 
table  and  this  covered  with  a  freshly-laundered  sheet.  A  small  stand  or  table 
is  placed  at  the  side  of  the  operator  and  covered  Avith  a  sterile  towel,  and  on 
this  are  placed  the  instruments,  ligatures,  sutures  and  sterilized  dressings. 
Upon  chairs  or  a  bench,  or  another  table,  two  or  three  basins  are  placed  con- 
taining boiled  water.  Into  one  of  these  a  sufficient  number  of  tablets  of 
corrosive  sublimate  are  thrown  to  make  a  solution  of  1  to  2,000. 

After  preparing  the  surface  to  be  operated,  and  the  surgeon's  hands,  as 
described  in  a  previous  section,  the  operation  may  proceed,  but  every  one 
connected  with  the  work  must  bear  in  mind  throughout  the  operation  that 
nothing  is  to  be  touched  by  any  one  except  those  things  that  have  been  steril- 
ized. If  anything  has  been  touched  by  accident  or  intentionally,  the  hands 
of  such  person  or  persons  must  again  be  disinfected. 

It  is  not  at  all  uncommon  after  making  the  most  careful  preparations  for 
an  asceptic  operation  to  have  some  one  who  comes  in  contact  with  the  wound, 
directly  or  indirectly,  thoughtlessly  produce  an  infection  by  handling  some 
object  which  is  not  sterile.  If  it  is  necessary  to  depend  upon  unskilled  assist- 
ants, it  is  well  to  cover  their  hands  with  sterilized  rubber  gloves  and  to  vir- 
tually perform  the  operation  alone.  It  is  well  to  carry  a  good  supply  of 
sterilized  towels  and  dressings  in  order  to  be  able  to  cover  everything  in  the 
vicinity  of  the  operation. 

Instruments  may  be  carried  sterile  in  a  canvas  roll  and  covered  with  a 


62  GENERAL  SURGICAL  CONSIDERATIONS 

sterile  towel,  and  the  ligatures  and  suture  material  may  be  carried  in  bottles. 
Basins  may  be  placed  in  a  wash  boiler  and  sterilized  by  boiling  while  the 
preparations  are  being  made  for  the  operation. 

Sterilized  gauze  may  be  cut  in  suitable  lengths  to  serve  as  sponges. 

From  this  it  will  be  seen  that  it  is  not  very  difficult  to  prepare  an  operat- 
ing room  in  an  ordinary  dwelling-house,  but  no  operator  ever  does  his  best 
work  anywhere  except  in  his  own  regular  operating-room. 

Simplicity  of  detail  to  be  studied.  Whether  the  operation  be  performed 
in  a  well-appointed  operating-room  or  in  a  dwelling  house,  much  will  be 
gained  for  the  patient  if  the  surgeon  appreciates  the  great  value  of  simplicity. 
If  only  that  is  done  which  is  actually  of  value  to  the  patient,  much  will  be 
gained  for  him,  because  it  is  through  unnecessary  manipulations  that  one  is 
especially  likely  to  carry  infection  to  the  wound. 

GENERAL  ANESTHESIA 

Ether  and  chloroform  are  the  only  two  general  anesthetics  which  seem  to 
have  stood  the  test  of  time ;  not  that  they  are  entirely  safe,  nor  that  they  are 
entirely  satisfactory,  but  rather  that  they  are  less  unsatisfactory  than  the 
other  substances  which  have  come  into  use  and  been  discarded  again.  With 
chloroform  there  is  a  considerable  amount  of  danger  at  the  time  of  its 
administration,  and  in  the  use  of  ether  there  is  some  danger  from  pneumonia 
following  recovery  from  the  anesthesia  because  of  the  great  irritation  of  the 
respiratory  tract. 

The  various  contra-indications  will  be  considered  in  connection  with  the 
clinical  cases  wherein  they  are  found.  For  the  present  only  points  of  general 
application  will  be  considered. 

General  influences.  The  careful  general  examination  which  was  described 
in  the  first  sections  will  have  determined  any  pathological  conditions  of  the 
heart,  the  kidneys  and  the  lungs,  the  three  organs  especially  to  be  studied 
by  the  anesthetist.  If  one  or  more  of  these  organs  have  been  found  to  be 
pathological  it  will  be  wise  for  the  anesthetist  to  be  even  more  cautious  than 
he  would  otherwise,  if  this  is  possible,  and  for  the  surgeon  to  limit  his  opera- 
tion to  the  very  shortest  consistent  time.  The  induction  of  anesthesia  should 
be  somewhat  slower  and  the  anesthesia  just  sufficiently  profound  to  permit 
the  operation  without  disturbance  or  interruption  by  the  patient. 

Organic  heart  lesions  not  positively  forbidding.  Singularly,  in  our  expe- 
rience patients  suffering  from  organic  heart  lesions  have  never  exhibited  any 
serious  or  alarming  difficulty  during  the  administration  of  an  anesthetic, 
while  patients  whose  heart,  lungs  and  kidneys  were  normal  at  the  time  of 
taking  anesthetics  have  sometimes  shown  serious  symptoms. 

In  a  symposium  on  this  subject  before  the  College  of  Physicians  of  Phila- 
delphia in  which  many  of  the  most  experienced  surgeons  of  this  country 
participated,  no  one  had  seen  a  death  from  anesthesia  in  any  case  in  which 
there  had  been  a  demonstrable  heart  lesion. 

No  one  would  reason  from  this  that  the  former  class  of  patients  are  better 
subjects  for  the  administration  of  anesthetics,  but  rather  that  the  presence 
of  their  unfavorable  condition  caused  the  anesthetists  to  exercise  unusual 
care  in  all  of  them. 

From  this  it  would  seem  that  it  is  perfectly  safe  to  give  anesthetics  in  cases 
suffering  from  valvular  heart  lesions,  provided  this  is  known  at  the  time  the 
anesthetic  is  administered.  We  believe  that  it  also  shows  that  if  the  same 
care  which  has  been  employed  in  these  cases  were  regularly  taken  in  all  cases, 
the  present  low  mortality  from  anesthesia  would  be  still  further  reduced. 


GENERAL  SURGICAL  CONSIDERATIONS  63 

Chloroform  followed  by  ether.  The  method  of  administering  chloroform, 
followed  by  ether,  which  has  been  satisfactory  in  our  own  practice,  although 
now  superseded  by  ether  alone,  consists  in  first  quieting  the  fears  of  the  patient, 
then  applying  across  the  patient's  eyes  a  piece  of  rubber  ten  cm.  wide  and 
jfifteen  cm.  long  and  over  this  a  pad  of  sterilized  gauze,  six  or  eight  thicknesses, 
and  about  three  inches  wide  and  eight  inches  long,  held  in  place  by  a  towel 
which  is  pinned  around  the  head  so  that  its  lower  margin  crosses  the  nose 
below  its  middle  to  protect  the  eyes  against  irritation  from  the  anesthetic, 
and  incidentally  to  soothe  the  patient  by  having  the  eyes  closed.  An  ordinary 
Esmarch  chloroform  mask  covered  with  two  thicknesses  of  stockinette  is  then 
placed  over  the  mouth  and  nose  and  chloroform  is  dropped  upon  this  very 
slowly  but  continuously,  care  being  taken  to  constantly  change  the  point  upon 
which  the  drops  fall  so  as  to  apply  the  chloroform  to  different  parts  of  the 
mask  with  uniformity.  Then  the  patient  is  told  to  count  aloud  slowly  after 
the  anesthetist,  who  speaks  numbers  of  three  figures  slowly,  then  waits  for  the 
patient  to  repeat  the  same  number,  then  he  calls  the  next  higher  or  lower 
number.  This  is  continued  until  the  patient  is  asleep.  By  choosing  a  large 
number  to  be  repeated  by  the  patient  the  latter  exhales  freely  while  counting 
and  later  inhales  quite  as  freely  while  the  anesthetist  repeats  the  next  number. 
His  attention  being  directed  toward  the  unusual  feature  prevents  him  from 
causing  any  voluntary  irregularity  in  his  respiration.  This  causes  him  to 
breathe  deeply  and  at  the  same  time  to  divert  his  attention  from  the  anesthesia. 

So  long  as  the  patient  counts  with  loud  voice,  after  the  anesthetist,  his 
breathing  is  fairly  regular  and  there  is  little  danger  in  the  administration  of 
chloroform,  provided  the  gauze  covering  the  mask  is  not  too  thick  to  permit 
a  sufficient  amount  of  air  to  enter  with  the  chloroform  (for  this  reason  only 
two  thicknesses  of  ordinary  gauze  or  stockinette  should  be  used). 

After  the  patient  has  been  thoroughly  anesthetized  with  chloroform,  and 
for  at  least  one  minute  before  the  operation  is  begun,  ether  is  administered 
with  the  same  mask,  also  by  the  drop  method,  with  the  difference,  however, 
that  the  gauze  is  kept  thoroughly  saturated  with  ether  and  that  four  layers 
of  gauze,  or  two  layers  of  stockinette,  are  placed  on  the  Esmarch  mask. 

Safety  of  the  method.  When  a  surgeon  is  compelled  to  operate  without  a 
skilled  anesthetist,  which  is  a  very  common  experience  for  the  practitioner 
in  the  country,  the  administration  of  the  ether  can  safely  be  placed  in  the 
hands  of  any  one,  provided  this  method  be  employed.  The  surgeon  can  pre- 
pare everything  for  the  operation,  he  can  then  give  the  chloroform  himself 
until  the  patient  is  asleep,  then  after  giving  ether  for  a  minute  or  more  this 
may  be  placed  in  the  hands  of  any  intelligent  person  and  the  surgeon  can  again 
disinfect  his  hands  and  proceed  to  perform  the  operation.  Even  in  hospitals 
where  there  are  skilled  anesthetists  this  method  is  satisfactory. 

If  for  any  reason  the  patient  does  not  take  ether  well  he  will  frequently 
take  chloroform  without  disturbance,  and  it  is  usually  well  to  change  the  anes- 
thetic in  any  case  in  which  there  seems  to  be  difficulty  with  giving  one  or  the 
other  or  these  two.  "We  have,  however,  adopted  the  rule  never  to  return  to 
the  use  of  chloroform  in  any  given  case  in  which  this  anesthetic  is  not  well 
taken,  fearing  that  it  might  result  in  a  serious  or  even  fatal  accident. 

If  the  patient  does  not  take  ether  well  it  may  be  disagreeable  to  continue  its 
use,  but  it  is  nevertheless  ordinarily  safe. 

Danger  signals.  There  is  no  sign  of  danger  in  the  administration  of  anes- 
thetics upon  which  one  can  depend  absolutely,  but  there  are  a  number  of  signs 
which  should  always  have  immediate  and  careful  attention  when  they  appear. 
In  most  cases  of  danger  respiration  is  at  first  impaired ;  in  some  the  respiration 
and  the  circulation  suffer  at  the  same  time,  Avhile  in  others  the  heart  stops 
beating  suddenly  before  the  respiration  ceases. 


64  GENEEAL  SURGICAL  CONSIDERATIONS 

As  soon  as  danger  signs  appear,  however,  the  ether  and  mask  should  be 
removed  at  once,  and  it  is  usually  not  well  to  apply  the  anesthetic  a  second 
time.  The  patient  who  may  cry  out  from  pain  in  the  later  stages  of  an  opera- 
tion is  better  ofit'  than  if  exposed  to  the  risk  of  further  anesthesia  if  he  has 
shown  signs  of  being  in  danger  of  serious  trouble  during  the  operation. 

Means  of  relief.  In  time  of  trouble  we  have  found  greater  benefit  and 
prompter  relief  by  first  pressing  forcibly  upon  the  chest  several  times,  in 
order  to  force  out  from  the  lungs,  as  much  as  possible,  the  air  laden  with 
chloroform,  and  then  by  means  of  artificial  respiration  suppljang  pure  air  in 
its  place. 

If  no  air  seems  to  enter  the  lungs  upon  attempting  artificial  respiration  it 
is  well  to  rapidly  place  a  gag  between  the  teeth  and  with  the  finger  to  raise 
up  the  epiglottis  away  from  the  larynx ;  this  can  sometimes  be  accomplished 
very  quickly  by  pulling  the  tongue  forward  rapidly  with  a  pair  of  tongue 
forceps. 

The  operator  can  frequently  recognize  impending  danger  to  the  patient 
from  the  anesthetic  by  the  lack  of  bleeding  from  the  wound  and  by  the  dark 
color  of  the  blood,  indicating  insufficient  aeration. 

Above  all  things,  the  anesthetist  should  give  his  entire  attention  to  his 
work  and  should  never  crowd  the  anesthetic  in  order  to  hasten  the  anesthesia. 

Preference  given  to  ether.  For  several  years  we  have  abandoned  the  use 
of  chloroform  anesthesia  completely  because  it  has  been  found  that  using  the 
drop  method  of  administering  ether,  which  was  first  introduced  in  the  Aug- 
ustana  Hospital  by  L.  H.  Prince  over  twenty-five  years  ago,  anesthesia  can  be 
accomplished  almost  without  either  immediate  or  remote  danger.  The  amount 
of  ether  given  is  thus  exceedingly  small,  and  the  patient  is  completely  under 
its  influence,  in  from  two  to  ten  minutes.  In  cases  in  which  two  ounces  of 
castor  oil  have  been  given  on  the  day  before  the  operation,  nausea  and  vomiting 
rarely  occurs.  The  patient  recovers  from  the  anesthetic  very  rapidly  and 
without  pulmonary  irritation. 

The  mask  invented  by  Ferguson,  which  is  constructed  of  malleable  copper 
wire  so  that  it  can  be  accurately  fitted  to  the  patient's  face,  is  most  useful; 
the  amount  of  ether  given  can  be  most  accurately  regulated  and  much  waste 
is  therefore  prevented. 

Morphin  and  atropin  hypodermically.  In  patients  with  irritable  bronchial 
mucous  membranes  it  is  well  to  administer  one-fourth  grain  of  morphin  and 
one  one-hundredth  grain  of  atropin  hypodermically  half  an  hour  before  begin- 
ning the  anesthetic.  This  will  prevent  the  accumulation  of  frothy  mucus 
during  the  administration  of  the  anesthetic,  which  is  especially  desirable  in 
operations  about  the  head  or  neck.  This  also  reduces  the  amount  of  ether 
required  for  accomplishing  satisfactory  anesthesia. 

It  is  to  be  remembered,  however,  that  whatever  anesthetic  and  whatever 
method  of  administration  may  be  chosen  it  is  always  of  great  importance  to 
the  patient  to  reduce  the  time  limit  to  a  minimum. 

NITROUS  OXIDE  GAS  ANESTHESIA 

During  the  past  few  years  many  surgeons  have  used  nitrous  oxide  gas 
anesthesia  for  operations  lasting  up  to,  and  even  beyond,  one  hour.  This 
gas  has  been  used  safely  in  an  enormous  number  of  dental  operations,  and  in 
other  short-term  operations  for  many  years  with  great  satisfaction. 

No  advantage  as  an  introductory  affent.  Of  late  it  has  been  used  for  gen- 
eral operative  work  in  many  cases  for  the  purpose  of  anesthetizing  the  patient 
primarily  to  avoid  the  annoyance  of  taking  ether,  and  later  continuing  the 
anesthesia  with  ether  or  chloroform.    In  order  to  determine  the  value  of  this 


GENERAL  SURGICAL  CONSIDERATIONS  65 

method  we  employed  it  in  one  hundred  successive  cases  and  compared  the 
anesthesia,  the  patient's  sensations  and  the  condition  of  the  patient  after  the 
operation  with  cases  operated  before  and  after  this  test  period  under  ether 
anesthesia  applied  by  the  drop  method.  We  found  no  difference  in  the  course 
of  the  anesthesia,  nor  in  the  comfort  of  the  patient,  but  there  was  a  little  more 
bronchial  irritation  following  operation  when  nitrous  oxide  gas  had  been  used. 
The  method  was  more  cumbersome  and  consequently  it  was  permanently  aban- 
doned. For  a  time  it  was  necessary  to  give  patients  the  choice  of  this  anes- 
thetic because  they  had  obtained  the  idea  elsewhere  that  it  was  much  safer 
and  so  some  were  slightly  prejudiced  in  favor  of  the  method,  but  aside  from 
the  slight  advertising  value,  which  the  method  undoubtedly  possesses,  we  are 
convinced  that  it  has  no  especial  value  as  compared  with  ether  properly 
administered  by  the  drop  plan. 

The  same  value  is  present,  possibly  to  a  somewhat  greater  degree,  in  the 
method  now  more  frequently  employed  of  a  combination  of  nitrous  oxide  gas 
and  oxygen.  Here  the  patient  is  successively  asphyxiated  by  the  use  of  nitrous 
oxide  gas  and  resuscitated  by  the  oxygen  gas.  A  skilled  anesthetist  can 
accomplish  these  two  processes  so  cleverly  that  any  operation  not  affected  by 
muscular  rigidity  can  be  performed  under  this  anesthesia. 

This  form  of  anesthesia  not  good  in  intra-abdominal  work.  In  intra- 
abdominal operations  we  have  found  the  additional  traumatism  necessitated 
by  the  rigidity  of  the  abdominal  muscles  causes  a  great  increase  in  the  pain 
suffered  by  the  patient  after  operation.  This  can,  however,  be  overcome  by 
giving  from  one-sixth  to  one-third  of  a  grain  of  morphia  with  one  one- 
hundredth  of  a  grain  of  atropin  half  an  hour  before  the  operation  is  com- 
menced, and  by  giving  morphia  after  operation  in  case  of  pain.  The  method 
undoubtedly  exposes  the  patient  to  conditions  which  cannot  be  considered 
harmless.  Were  a  patient  exposed  to  the  same  degree  of  asphyxia,  for  the 
same  period  of  time,  from  any  other  cause,  it  seems  reasonable  to  suppose  that 
any  physician  would  look  upon  this  as  a  severe  strain  upon  the  physiological 
processes.  After  the  newness  of  this  method  has  worn  off,  these  secondary 
considerations  will  undoubtedly  receive  more  careful  attention. 

Other  contraindications.  It  seems  wise  never  to  follow  this  course  of  anes- 
thesia in  any  operation  lasting  longer  than  a  few  minutes,  unless  a  well-trained 
anesthetist  is  available,  and  then  never  in  plethoric  patients  nor  in  cases  suffer- 
ing from  cardiac  dilatation,  myocarditis,  valvular  heart  lesions,  nor  in  those 
suffering  from  obstruction  to  respiration  from  any  cause.  Patients  with 
arterio-sclerosis  or  with  high  blood  pressure  are  also  bad  subjects  for  the  use 
of  this  form  of  anesthesia. 

The  use  of  nitrous  oxide  anesthesia  is  especially  contraindicated  in  condi- 
tions such  as  severe  anemia,  lowered  or  much  increased  blood  pressure,  dia- 
betes, advanced  nephritis,  status  lymphaticus,  morbus  Basedowi,  Addison's 
disease,  myocarditis,  advanced  cardiac  and  pulmonary  disease.  In  these  cases 
the  use  of  local  anesthesia  should  be  considered. 

In  cases  in  which  this  form  of  anesthesia  seems  safe,  it  is  not  needed  be- 
cause they  do  equally  well  with  the  use  of  ether  by  the  drop  method,  and  in 
those  in  which  one  dislikes  to  give  ether  this  method  is  contraindicated.  For 
some  time  to  come  there  will  be  a  certain  amount  of  advertising  advantage, 
but  as  soon  as  this  has  been  dissipated  by  the  fact  that  everyone  will  be  pre- 
pared to  administer  this  form  of  anesthesia,  its  drawbacks  must  become 
apparent  as  compared  with  its  advantages. 

Indications.  Nitrous  oxide  anesthesia  is  satisfactory  to  use  in  short  minor 
operations,  such  as  pulling  teeth,  opening  abscesses,  etc.,  but  not  when  com- 
nlete  muscular  relaxation  is  desired.     The  only  real  merits  are  the  comfort  to 


ee  GENERAL  SURGICAL  CONSIDERATIONS 

the  patient  in  inducing  the  anesthesia,  and  the  rapidity  with  which  patients 
regain  consciousness. 

Ether  is  the  best  general  anesthesia.  Ether  anesthesia  when  applied  prop- 
erly by  the  drop  method  is  no  less  comfortable,  and  if  interrupted  when  the 
surgeon  begins  to  apply  the  sutures  the  patient  will  awaken  almost  immediately 
after  the  conclusion  of  the  operation,  but  will  then  usually  again  fall  asleep 
and  so  remain  naturally  for  several  hours,  while  after  nitrous  oxide  anesthesia 
he  is  likely  to  be  kept  awake  by  the  pain  in  the  wound  unless  morphia  is 
administered.  Bronchial  irritation  is  not  more  common  after  ether  anesthesia, 
if  carried  out  as  described  heretofore,  than, after  nitrous  oxide  anesthesia.  If 
the  plan  of  administering  two  ounces  of  castor  oil  twenty-four  hours  before 
the  operation  is  strictly  adhered  to,  there  is  almost  no  vomiting,  no  matter 
what  anesthetic  may  be  employed. 

LOCAL  ANESTHESIA   OR   ANALGESIA 

The  use  of  substances  injected  into  the  tissues  to  produce  anesthesia  in 
a  local  area  has  become  popularized  to  v  marked  degree  during  the  past 
few  years.  In  fact,  some  surgeons  are  using  this  method  in  a  large  propor- 
tion of  their  routine  cases. 

There  should  be  no  doubt  as  to  the  extent  of  the  operation,  because  the 
anesthetic  being  limited  to  a  local  area,  dragging  of  the  tissue  may  affect 
other  organs  beyond  the  area  of  anesthesia.  In  some  instances  the  adminis- 
tration of  a  local  anesthetic  may  be  more  painful  than  the  operation  itself, 
and  this  would,  of  course,  bar  its  use.  All  anesthetics  have  their  disadvantages 
and  dangers. 

Consciousness  a  disadvantage.  Consciousness  during  the  operation  is  a 
great  disadvantage  to  the  operator  unless  he  has  the  confidence  of  the  patient. 
It  is  almost  impracticable  with  many  nervous  individuals  and  children.  In 
such  the  shock  of  apprehension  may  be  greater  than  that  which  may  result 
from  the  use  of  a  general  anesthetic. 

Methods  of  action.  Local  anesthetics  act  in  one  of  three  ways,  viz. :  1st, 
By  producing  an  anemia  of  the  capillaries  supplying  the  nerve-endings.  2d, 
By  direct  action  on  the  nerve-endings.    3d,  By  direct  action  on  the  nerve-fibres. 

When  about  to  perform  an  operation  under  local  anesthesia  all  preparations 
should  be  completed  before  the  patient  is  brought  into  the  room.  During  the 
operation  the  patient's  face  should  be  covered,  unnecessary  conversation 
should  be  avoided  and  comparative  silence  should  prevail.  Stimulants  should 
be  at  hand,  and  the  patient  should  be  carefully  watched. 

The  chief  object  of  this  method  is  to  produce  anesthesia  over  a  limited  area, 
therefore  a  constricting  band  above  the  field  of  operation  or  the  use  of  adren- 
alin are  advisable,  for,  not  only  do  they  limit  the  field  of  action  but  they  also 
diminish  the  amount  of  anesthetic  required  and  the  hemorrhage  following. 

Most  common  drugs.  The  drugs  most  commonly  used  for  the  purpose  of 
producing  local  anesthesia  are  cocaine,  beta-eucaine,  novocain,  tropacocain  and 
ethyl-chloride.  We  have  been  in  the  habit  of  using  cocaine  for  a  number  of 
years  and  to  entire  satisfaction.  Also  a  1/2  per  cent,  solution  of  novocain,  has 
been  most  satisfactory  in  our  practice. 

Cocaine.  Cocaine  when  applied  to  the  unbroken  skin  produces  no  effect. 
When  applied  to  the  mucous  membrane  or  when  injected  beneath  the  skin  it 
causes  a  tingling  sensation,  followed  by  a  paralysis  of  sensation  due  to  its 
toxic  effect  upon  the  nerve  endings.  It  also  produces  anemia  from  constric- 
tion of  the  capillaries,  followed  by  hyperemia  from  secondary  dilatation.  The 
local  action  of  cocaine  is  very  brief,  after  which  jt  js  rapidly  absorbed,  aud 
may  produce  coijstitu.tion3,l  symptojns. 


GENERAL  SURGICAL  CONSIDERATIONS  67 

At  first  the  use  of  cocaine  was  limited  to  small  areas,  later  the  application 
of  the  constriction  band  above  the  field  allowed  more  surface  to  be  used  so  that 
more  extensive  operations  could  be  performed.  "With  the  discovery  of  adren- 
alin, Braun  suggested  its  use  in  combination  with  cocaine.  The  danger  of  the 
former  method  was  that  it  only  delayed  constitutional  symptoms.  Adrenalin 
being  a  hemostatic  diminishes  hemorrhage,  retards  absorption  and  limits  the 
action  of  the  cocaine  to  a  given  area,  consequently  a  less  amount  is  necessary 
and  the  anesthesia  is  prolonged  from  one  to  three  hours. 

Preparation  of  solution.  Cocaine  hydrochloride  is  the  preparation  most 
frequently  used.  It  is  soluble  in  chloroform,  alcohol  and  water.  In  the  prepar- 
ation of  the  aqueous  solution  for  surgical  purposes,  great  care  must  be  taken 
in  the  process  of  sterilization  and  in  the  avoidance  of  chemical  contamination. 
Only  a  physiological  salt  solution  in  distilled  water  should  be  used.  This  is 
very  important,  otherwise  intense  burning  sensation  may  follow  its  applica- 
tion. As  cocaine  loses  its  anesthetic  property  when  brought  to  the  boiling  tem- 
perature (100  C.)  sterilization  may  be  accomplished  by  heating  the  solution  at 
80  C.  for  one-half  hour  on  two  successive  days.  After  the  solution  is  sterilized 
and  the  temperature  reduced  to  blood-heat,  an  equal  amount  of  a  one  to  one 
thousand  solution  of  adrenalin  chloride  is  added.  Adrenalin  decomposes  at 
boiling  temperature.  An  air-tight  metal  or  glass  syringe  is  very  essential. 
The  needle  is  inserted  just  beneath  and  almost  parallel  with  the  epidermis  in 
the  direction  of  the  line  of  incision.  The  solution  is  then  slowly  injected  until 
an  anemic  area  is  produced  into  which  the  needle  is  gradually  advanced,  more 
solution  being  injected  continuously.  When  the  needle  will  not  advance  any 
further,  it  is  withdrawn  and  the  process  then  repeated.  By  injecting  just  be- 
neath the  epidermis  the  cocaine  comes  in  direct  contact  with  the  nerve-endings 
and  there  is  very  little  absorption. 

Schleich's  infiltration  method.  In  cases  such  as  goitre  and  extensive 
lipomata  in  which  a  large  amount  of  solution  is  required,  this  method  is 
preferred. 

Schleich  employs  three  solutions  containing  0.2  (strong),  0.1  (normal), 
0.01  (weak)  parts  of  cocaine  hydrochloride,  to  which  are  added  sodium 
chloride  0.2,  morphine  hydrochloride  0.025,  and  sterile  distilled  water  sufficient 
to  make  100  parts. 

For  this  method  a  long  needle  is  required.  The  solution  is  injected  just 
beneath  the  epidermis  and  then  into  the  deeper  tissues  about  the  diseased  area. 
By  this  means  anesthesia  is  partly  produced  by  the  cocaine  and  partly  by  the 
pressure  of  the  water. 

As  much  as  100  cc.  of  the  weak  solution  may  be  used  before  the  incision  is 
made  and  later  during  the  progress  of  the  operation  it  is  perfectly  safe  to 
inject  up  to  500  cc. 

During  the  past  few  years  we  have  used  in  this  method,  novocaine  in  % 
per  cent,  solution,  as  its  toxicity  is  less  than  that  of  cocaine,  especially  when 
used  with  adrenalin  solution. 

REGIONAL  ANESTHESIA 

This  method  of  anesthesia  was  first  introduced  by  Braun  and  is  of  great 
practical  value  in  certain  operations  which  may  be  too  extensive  for  the  infil- 
tration method  and  in  which  a  general  anesthetic  is  contra-indicated.  This  is 
especially  true  for  operations  on  the  extremities,  but  in  order  that  it  may  be 
carried  out  successfully  an  accurate  knowledge  of  the  peripheral  nerves  is 
essential. 

"Where  the  peripheral  sensory  nerves  are  superficial,  as  in  the  hands  and 
feet,  the  transverse  circular  or  semi-circular  subcutaneous  infiltration  of  a  two 


68  GENERAL  SURGICAL  CONSIDERATIONS 

per  cent,  cocaine  solution  will  render  the  skin  below  insensible  to  pain.  This 
method  is  frequently  employed  for  operations  on  the  fingers  and  toes. 

Perineural  method.  For  the  performance  of  operations  on  the  extremities 
in  which  deep  anesthesia  is  required,  the  injection  of  a  two  per  cent,  solution 
of  cocaine  and  adrenalin  about  the  nerve  sheath  "will  paralyze  the  nerve  in 
from  ten  to  thirty  minutes,  and  anesthesia  of  the  parts  to  which  it  is  distrib- 
uted will  last  from  one  to  three  hours.  This  is  known  as  the  perineural  method 
of  anesthesia.  No  harm  is  done  to  the  nerve  and  the  shock  which  so  frequently 
follows  the  section  of  a  large  trunk  nerve  is  avoided. 

Accessible  nerves.    The  following  nerves  are  accessible  for  this  method : 

The  supra-orbital  branch  of  the  trigeminal  just  above  the  supra-orbital 
notch. 

The  ulnar  behind  the  internal  condyle  of  the  humerus  beneath  the  deep 
fascia  where  it  perforates  the  internal  intermuscular  septum,  also  above  the 
wrist  beneath  the  inner  side  of  the  flexor  carpi  ulnaris. 

The  median  just  above  the  annular  ligament  of  the  wrist  on  the  inner  side 
of  the  palmaris  longus. 

The  internal  popliteal  along  the  inner  border  of  the  biceps  tendon  behind 
the  head  of  the  fibula. 

The  occipital  major  as  it  passes  through  the  outer  border  of  the  trapezius. 

The  aurico-temporal  as  it  passes  backward  and  outward  betAveen  the  lateral 
ligaments  of  the  temporo-maxillar}"  joint  and  the  condyle  of  the  jaw  close  to 
the  temporal  artery. 

The  lingual  at  the  point  where  the  palato-glossal  fold  and  the  floor  of  the 
mouth  meet. 

The  great  auricular,  occipital  minor  and  the  superficial  cervical  along  the 
posterior  border  of  the  sterno-cleido-mastoid. 

The  superior  laryngeal  behind  the  cornua  of  the  hyoid  bone  where  it  passes 
through  the  thyro-hyoid  membrane. 

The  dorsal  nerve  of  the  penis  in  the  region  of  the  dorsal  artery. 

Endoneural  method.  It  has  been  found  that  by  injectino:  a  1  per  cent, 
cocaine  solution  with  adrenalin  directly  into  the  nerve  trunk  the  same  results 
may  be  obtained  as  with  the  perineural  method.  This  is  known  as  the  endo- 
neural method.  The  only  advantage  is  that  anesthesia  is  produced  more 
promptly.  The  disadvantages  are  that  it  can  only  be  used  on  large  nerve 
trunks.  The  nerve  must  first  be  exposed,  and  not  infrequently  a  neuritis 
follow^s.  This  method  may  be  used  on  the  crural,  the  sciatic  and  the  brachial 
plexus. 

Bodine  and  Gushing  have  introduced  a  method  of  anesthesia  for  hernia 
operations.  They  start  the  operation  with  the  infiltration  method  and  then 
inject  the  ilio-hypogastric  and  ilio-inguinal  nerves  as  the  operation  progresses. 

Intravenous  method.  One  of  the  latest  methods  of  regional  anesthesia  is 
that  introduced  by  Bier  and  known  as  vein  anesthesia.  AA^hile  as  yet  it  is  not 
generally  accepted  by  the  profession  it  is  of  some  practical  value  and  therefore 
worthy  of  mention. 

It  is  only  used  for  operations  on  the  extremities. 

The  blood  is  first  carefully  expelled  from  the  extremity  by  bandaging  from 
the  periphery  toward  the  field  of  operation.  A  soft  rubber  bandage  is  then 
applied  above  the  field  so  as  to  produce  constriction  over  a  broad  surface.  A 
second  similar  bandage  is  then  applied  below.  A  subcutaneous  vein  between 
the  two  bandages  is  then  exposed  and  a  weak  solution  of  cocaine  is  injected 
toward  the  valves.  Anesthesia  usually  follows  in  two  to  fifteen  minutes.  The 
cocaine  is  dissolved  in  a  physiological  salt  solution  which  penetrates  the  walls 
of  the  veins  and  acts  on  the  nerve  endings  as  well  as  the  nerve  trunks.     The 


GENERAL  SURGICAL  COXSIDERATIOXS  69 

bloodless  condition  of  the  parts  allows  of  very  little  absorption  and  a  large 
part  of  the  solution  escapes  from  the  wound,  so  that  there  is  very  little  danger 
of  constitutional  symptoms.  To  further  insure  safety,  Bier,  before  closing  the 
wound,  removes  the  peripheral  bandage  and  loosens  the  proximal  so  that  the 
arteries  are  open  but  the  veins  are  still  compressed.  AYhen  the  limb  is  pink 
and  bleeds  freely  the  tissues  are  thoroughly  washed  in  order  to  remove  as  much 
as  possible  of  the  solution.  The  bandage  is  again  tightened  and  the  wound 
sewed  up  before  anesthesia  subsides.  If  a  large  amount  of  anesthetic  has  been 
used,  Bier  washes  the  vessels  through  a  canula  with  physiological  salt  solu- 
tion, which  runs  out  through  the  wound.  Bier  refrains  from  using  this  form 
of  anesthesia  in  senile  or  diabetic  cases. 

It  may  be  used  for  operations  on  the  extremities  as  a  substitute  for  spinal 
anesthesia,  being  more  simple  and  harmless. 

SPINAL  ANESTHESIA 

Spinal  anesthesia  was  first  introduced  by  Bier  following  the  discovery  by 
Corning  that  cocaine  when  applied  to  a  nerve  trunk  produces  anesthesia  of 
the  region  which  it  supplied. 

Dangers  and  advantages.  The  mortality  following  this  form  of  anes- 
thesia is  far  greater  than  after  ether,  and  therefore  should  only  be  used  when 
the  patient  can  not  take  the  latter  and  when  local  or  regional  anesthesia  is 
impracticable.  It  has  no  advantage  over  ether.  The  headache,  nausea  and 
retching  which  may  follow  its  use  may  be  more  persistent  than  after  ether,  so 
that  a  spinal  puncture  may  be  required  to  relieve  it.  Collapse  and  even  sudden 
death  may  occur  during  its  application.  Focal  paralysis  and  even  trophic  dis- 
turbances may  follow  its  use.  AYith  the  introduction  of  newer  methods  of 
cocainization,  its  use  is  now  practically  limited  to  the  upper  half  of  the 
abdomen. 

There  is  no  pulmonary  irritation.  The  patient  being  conscious  may  be  able 
to  aid  the  operator.  There  is  complete  muscular  relaxation  and  no  intestinal 
protrusion. 

But  it  may  fail  in  its  purpose.  Any  accident  during  the  operation  alarms 
the  patient  and  embarrasses  the  surgeon.  In  advanced  cases  of  cardiac  disease, 
the  shock  of  apprehension  may  be  worse  than  that  from  the  operation  itself. 
The  operation  must  be  completed  within  an  hour  and  a  half.  Pelvic  cases  are 
unsafe  unless  the  Trendelenburg  posture  is  dispensed  with.  Spinal  anesthesia 
cannot  be  stopped  once  it  is  startecl. 

Injury  to  the  spinal  cord;  hemorrhage  into  the  subdural  space:  infection  of 
the  meninges,  and  anesthesia  of  the  higher  centers  are  the  chief  dangers. 

The  main  object  in  the  production  of  spinal  anesthesia  is  to  localize  the 
action  of  the  drug.  In  order  to  do  this  diffusion  and  gravitation  must  be  over- 
come. The  specific  gravity  of  the  spinal  fluid  is  1.007,  therefore,  a  solution  of 
greater  or  lesser  specific  gravity  is  safer,  this  depending  on  the  position  of  the 
patient.  The  use  of  spinal  fluid  as  a  vehicle  for  the  cocaine  has  been  adopted 
with  excellent  results  by  Morton  in  hundreds  of  cases.  To  prevent  diffusion 
a  viscid  substance,  such  as  glucose,  has  been  recommended.  This  is  quite 
unnecessary,  although  theoretically  it  looks  attractive.  Such  a  solution  forms  a 
stratum  so  that  the  action  of  the  cocaine  is  concentrated  at  one  point  and  being 
of  greater  specific  gravity,  gravitates  to  the  most  dependent  part  of  the  spinal 
canal. 

The  use  of  adrenalin  retards  absorption  and  prolongs  anesthesia,  but  does 
not  prevent  diffusion  so  that  the  higher  centers  of  the  medulla  may  become 
affected. 


70  GENERAL  SURGICAL  CONSIDERATIONS 

Points  of  injection.  The  region  in  which  the  spinal  puncture  is  to  be  made 
should  be  as  carefully  prepared  as  for  any  operation.  The  patient  is  placed 
in  the  sitting  posture  with  the  feet  hanging  over  the  side  of  the  bed,  or  if 
unable  to  do  this  he  should  be  placed  on  his  side  with  the  head  elevated.  For 
this  procedure  a  good,  graduated  syringe  with  a  long  needle  and  stylet  are 
required.  The  needle  is  inserted  between  the  third  and  fourth,  or  the  fifth  and 
sixth  lumbar  vertebrae  between  the  spines  or  the  laminae.  The  former  is  pre- 
ferred, there  being  less  danger  of  injury  to  the  cauda  equina,  and  there  is  less 
liability  of  unilateral  anesthesia.  A  needle  with  the  opening  on  the  side  is  to 
be  preferred  so  that  as  soon  as  the  needle  enters  the  canal,  fluid  will  appear. 
As  soon  as  the  needle  enters  the  sac  the  stylet  is  removed  and  unless  fluid 
appears  one  is  not  certain  that  he  is  in  the  spinal  canal. 

Ethyl  chloride.  This  substance  is  very  volatile  and  when  applied  to  the 
skin  evaporates  rapidly,  producing  a  great  amount  of  cold.  As  a  general 
anesthetic  its  use  is  limited  to  short  operations  and  except  in  the  hands  of  an 
expert  it  is  associated  with  great  danger.  Its  advantages  over  ether  are  the 
brief  period  of  excitation,  the  prompt  return  to  consciousness,  and  the  absence 
of  disagreeable  after-eft'ects.  Locally,  it  can  only  be  used  where  a  single 
incision  is  required  and  for  the  introduction  of  aspirating  or  transfusion 
needles.  It  is  sponged  upon  the  surface  until  the  skin  is  frozen  into  a  hard 
white  mass,  then  the  slight  operation  is  performed  before  the  heat  of  the  body 
and  the  temperature  of  the  room  have  thawed  out  the  frozen  skin.  The 
afterpain  is  rather  more  severe  than  in  case  of  general  anesthesia,  but  as  the 
wounds  are  alwa3^s  small,  this  is  of  no  great  importance. 

A  ready  freezing  mixture.  The  same  end  can  be  accomplished  by  placing 
equal  parts  of  chipped  ice  and  table-salt  in  a  piece  of  sterile  gauze  of  about 
four  thicknesses  and  holding  this  for  about  one  minute  directly  upon  the  area 
which  is  to  be  incised  or  punctured.  This  will  freeze  the  skin  quite  as  effec- 
tively as  the  ethyl  chloride  spray.  The  gauze  may  be  moistened  with  a  one  to 
2,000  solution  of  corrosive  sublimate  in  order  to  insure  antiseptic  conditions. 
This,  however,  is  not  necessary,  because  clean  table-salt  and  clean  ice  are  both 
sufficiently  free  from  pathogenic  micro-organisms  to  make  their  use,  as 
described  above,  safe. 

Scopolamin  and  morphin.  We  are  firmly  convinced  that  the  use  of  scopo- 
lamin  with  morphin  for  the  purpose  of  anesthesia  is  to  be  warned  against.  It 
is  a  very  powerful  drug  combination,  difl'erent  preparations  of  which  vary  in 
activity.  Confusion  and  violent  delirium  may  follow  its  administration.  We 
have  employed  this  method  sufficiently  often  to  be  convinced  that  it  is  much 
more  dangerous  than  ether  anesthesia  by  the  drop  plan.  In  cases  in  which  it 
seems  indicated,  we  greatly  prefer  to  give  morphine,  one-sixth  to  one-third 
grain,  with  atropin  one  one-hundred-and-fiftieth  to  one  one-hmidredth  grain, 
hypodermically,  half  an  hour  before  beginning  the  administration  of  the 
anesthetic. 

Various  modifications  of  the  original  plan  of  using  scopolamin  and  mor- 
phine have  been  suggested  and  other  drugs  like  hyoscin  have  been  substituted, 
but  the  effect  is  the  same.  If  used  in  small  quantities  they  seem  no  more  effi- 
cient than  morphine  alone,  and  when  used  in  large  quantities  they  appear 
much  more  dangerous. 

ETHYL  CHLORIDE 

One  of  the  results  of  the  present  war  has  been  to  bring  ethyl  chloride  into 
prominence  and  favor  as  a  general  anesthetic.  For  years  ethyl  chloride  has 
been  employed  merely  as  a  local  anesthetic,  although  its  property  of  producing 


GENERAL  SURGICAL  CONSIDERATIONS  71 

general  anesthesia  has  been  known  and  utilized  by  a  few.  Probably  because  it 
is  so  little  known  and  used,  ethyl  chloride  has  been  considered  as  unsafe,  but 
those  who  can  speak  with  authority  consider  it  safe  and  efficient  when  admin- 
istered for  transient  anesthesia. 

Ethyl  chloride  should  be  employed  as  a  general  anesthetic,  first  as  a  pre- 
liminary to  general  ether  narcosis,  or  in  cases  requirin,g  an  anesthesia  of  short 
duration,  in  which  a  local  anesthetic  for  one  reason  or  another  is  not  adaptable. 

Ethyl  chloride  as  a  general  anesthetic  is  useful  in  the  following  conditions : 
Incision  and  drainage  of  abscesses  or  furuncles ;  curettage  or  cautery  of 
wounds  and  ulcers ;  enlarging  of  wounds  for  drainage ;  insertion  of  drains ; 
removal  of  drains  and  packs ;  renewal  of  dressings ;  loose  suturing  of  gaping 
wounds ;  operations  for  ingrown  toe-nails ;  tenotomy ;  removal  of  foreign 
bodies;  insertion  of  pegs  and  hooks  for  extension;  as  a  preliminary  to  ether. 

Technique  of  administration.  Preliminary  preparation  or  medication  is  not 
necessary,  although  on  general  principles  it  is  preferable  that  the  stomach  be 
empty.  As  in  all  general  anesthetics,  loose  objects  should  be  removed  from  the 
mouth  and  the  respiratory  passages  should  be  clear.  The  patient  should  lie 
with  the  head  low  and  the  clothing  loosened  at  the  neck.  Restraint  is  not 
necessary.  The  eyes  are  covered  and  a  pad  of  gauze  of  eight  to  ten  layers  in 
thickness  is  placed  over  the  nose  and  mouth.  The  patient  is  instructed  to 
count  slowly  and  ethyl  chloride  is  sprayed,  or  better  rapidly  dropped,  upon  the 
gauze.  AYithin  one-half  to  two  minutes  anesthesia  is  completed,  as  evidenced 
by  the  patient  ceasing  to  count,  and  by  the  deep,  stertorous  respiration.  The 
ethyl  chloride  may  be  cautiously  continued  for  two  or  three  minutes  before 
being  discontinued.  Complete  anesthesia  persists  for  two  to  three  minutes 
from  the  discontinuance  of  the  administration  of  the  ethyl  chloride.  Conscious- 
ness returns  rapidly,  often  instantly.  Following  the  period  of  profound  anes- 
thesia there  is  often  a  short  analgesic  state.  There  may  be  a  brief  stage  of 
excitement  just  at  the  waking  moment.  With  the  exception  of  occasional 
profuse  perspiration,  there  are  no  unpleasant  after-effects.  When  the  stage  of 
complete  anesthesia  has  been  reached  it  can  easily  be  continued  with  ether  by 
simply  substituting  the  gauze  pad  with  a  mask  saturated  with  ether,  and  from 
this  point  employing  the  usual  drop  method.  Although  anesthesia  is  profound, 
there  is  seldom  complete  muscular  relaxation,  and  on  this  account  the  anes- 
thesia is  not  satisfactory  in  the  reduction  of  dislocations  and  fractures. 

RECTAL  ANESTHESIA 

The  advantage  of  this  method  must  be  apparent  if  further  experience  does 
not  show  harmful  effects. 

Advantages  claimed.  The  following  advantages  are  claimed  by  those  who 
have  employed  it. 

1.  The  amount  of  ether  used  is  very  much  smaller  than  by  inhalation 
method. 

2.  There  is  no  stage  of  excitation. 

3.  There  is  no  irritation  of  the  respiratory  mucous  membranes. 

4.  The  anesthetist  does  not  approach  the  field  of  operation. 

5.  Besides  being  out  of  the  way  he  also  is  unable  to  infect  the  woiuid. 

6.  The  patient  awakens  almost  at  once  after  the  anesthetic  is  stopped. 

7.  There  is  said  to  be  less  nausea  and  vomiting,  probably  because  the 
patient  has  not  swallowed  quantities  of  mucus  saturated  with  ether. 

8.  There  is  no  depressing  effect  upon  the  heart. 

It  is,  however,  to  be  remembered  that  all  of  these  advantages  are  also 


72  GENERAL  SURGICAL  CONSIDERATIONS 

obtained  if  the  method  is  employed  which  has  just  been  described  of  thoroughly 
anesthetizing  the  patient  by  inhalation  and  then  stopping  the  anesthetic  and 
elevating  the  head  during  head  and  neck  operations. 

Method  of  application.  It  is  in  the  first  place  most  important  that  the 
colon  be  empty  at  the  time  of  administration  of  ether  by  rectum,  because  the 
presence  of  feces  will  prevent  the  rapid  absorption  of  ether  and  the  openings 
in  the  tube  through  which  the  ether  fumes  are  introduced  may  become  clogged 
and  thus  the  introduction  in  sufficient  quantities  of  the  anesthetic  may  be 
prevented. 

In  order  to  secure  an  empty  colon  two  ounces  of  castor  oil,  preferably  in 
beer  foam,  should  be  given  twenty-four  hours  before  the  operation ;  twelve 
hours  later  the  patient  should  receive  a  large  cleansing  enema  of  soap  suds 
and  normal  salt  solution  and  this  enema  should  be  repeated  three  hours 
before  the  operation.  In  the  meantime  no  food  should  be  given  except 
broths  and  gruels,  in  order  that  there  may  not  be  any  fresh  intestinal 
accumulation. 

The  patient  is  placed  upon  the  table,  the  surface  of  the  neck  thoroughly 
prepared  and  then  covered  with  a  piece  of  sterile  gauze  saturated  with  alco- 
hol. The  hair  is  covered  and  a  gauze  pad  is  placed  across  the  mouth  and 
nose  as  described  previously,  in  fact  the  preliminary  preparation  is  identical 
with  that  employed  if  the  operation  is  to  be  performed  under  ether  anesthesia 
by  inspiration.  An  assistant  also  draws  the  lower  jaw  forward  and  holds 
it  in  that  position  throughout  the  operation. 

An  ordinary  soft  rubber  rectal  tube  with  an  opening  at  the  end  is  then 
slowly  introduced  into  the  rectum  a  distance  of  eight  or  ten  inches.  The 
tube  should  be  thoroughly  lubricated  in  order  to  prevent  annoyance  by  fric- 
tion. The  gas  contained  in  the  rectum  is  thus  permitted  to  escape  in  order 
to  facilitate  the  absorption  of  ether.  The  rectal  tube  is  then  attached  to 
the  tube  through  which  the  ether  fumes  are  pumped  into  the  rectum.  The 
colon  is  then  slowly  filled  with  ether  fumes  and  then  the  rectal  tube  is  once 
more  disconnected  in  order  that  any  remaining  intestinal  gas  which  was  not 
evacuated  primarily  may  escape.  This  procedure  may  be  repeated  several 
times,  care  being  taken  that  the  ether  fumes  are  not  injected  too  rapidly  for 
fear  of  too  great  distension  or  irritation.  At  first  some  gas  may  escape  along 
the  side  of  the  rectal  tube,  but  this  can  soon  be  prevented  by  injecting  only 
just  enough  gas  to  fill  the  colon.  There  may  be  slight  colicky  pains  at  first, 
but  the  patient  will  soon  become  accustomed  to  the  sensation.  If  the  castor 
oil  and  the  enema  have  acted  satisfactorily,  there  will  be  no  annoyance  from 
defecation  or  clogging  of  the  rectal  tube.  The  full  anesthesia  will  occur  in 
from  five  to  fifteen  minutes,  and  the  operation  can  be  performed  with  the 
consumption  of  from  one  to  three  ounces  of  ether. 

When  the  operation  is  completed  to  the  point  of  suturing  the  external 
wound,  the  apparatus  is  detached  from  the  rectal  tube  and  the  accumulated 
gas  in  the  colon  will  thus  be  permitted  to  escape.  If  the  patient  is  slightly 
conscious  of  the  application  of  the  skin  sutures,  the  consequent  deep  breath- 
ing will  facilitate  the  excretion  of  most  of  the  ether  contained  in  the  blood 
through  expired  air.  It  also  facilitates  the  expulsion  of  any  ether  fumes 
which  may  still  remain  in  the  colon.  This  can  be  further  favored  by  making 
gentle  abdominal  massage. 

The  patient  must  be  observed  throughout  the  period  of  administration 
with  the  same  care  as  when  ether  is  given  through  the  respiratory  tract. 
Cyanosis  will  almost  never  occur  if  the  lower  jaw  is  held  forward  as  stated. 
The  pulse  and  respiration  will  indicate  the  progress  of  the  anesthesia.     It  is 


GENERAL  SURGICAL  CONSIDERATIONS  73 

rarely  necessary  to  disconnect  the  rectal  tube  from  the  apparatus  and  to 
make  abdominal  massage  to  force  the  ether  fumes  out  of  the  rectum  during 
the  operation,  but  in  case  of  necessity  this  could  be  readily  done.  If  the 
head  is  elevated  after  the  operation  is  begun,  almost  no  anesthetic  will  be 
required  during  the  actual  progress  of  the  operation. 

Apparatus.  Various  forms  of  containers  have  been  invented  for  pro- 
ducing the  ether  fumes  utilized  in  this  form  of  anesthesia.  A  simple,  deep 
bottle  constructed  on  the  general  plan  of  wash  bottles  used  in  chemical  labora- 
tories seems  to  suffice  perfectly  if  mounted  on  a  stand  which  can  be  easily 
moved  without  breaking  the  bottle  or  its  attachments.  The  bottle  should  be 
fitted  with  a  rubber  stopper  with  two  holes,  one  of  which  contains  a  glass 
tube  whose  lower  end  is  even  with  the  stopper  and  whose  upper  end  is 
attached  to  a  rubber  tube  which  in  its  turn  is  fastened  to  a  glass  tube  for 
attachment  to  the  rectal  tube.  The  other  hole  contains  a  glass  tube  with 
bulb-shaped  lower  end  containing  many  small  perforations  and  reaching  to 
the  bottom  of  the  bottle.  The  upper  end  of  this  projects  through  the  upper 
surface  of  the  rubber  stopper  a  sufficient  distance  to  permit  the  attachment 
of  a  rubber  tube,  the  other  end  of  which  is  attached  to  a  bulb  with  which  air 
can  be  forced  into  the  bottle.  The  bottle  should  be  at  least  thirty  centi- 
meters deep  so  that  the  air  can  be  forced  through  a  considerable  column 
of  ether.  The  bottle  is  filled  with  ether  to  a  point  five  cm.  from  the  lower 
surface  of  the  cork,  the  upper  portion  of  the  bottle  being  left  as  a  gas 
space. 

This  bottle  should  be  immersed  in  a  vessel  containing  water  at  a  tem- 
perature of  from  80  to  100  degrees  F.,  according  to  various  clinicians,  the 
boiling  point  of  ether  being  98.8  degrees  F.  A  thermometer  is  to  be  placed 
in  the  water  and  a  stopcock  at  the  lower  part  will  make  it  possible  to  remove 
the  water  when  the  temperature  has  become  too  low. 

According  to  another  method  which  has  also  been  frequently  used  and 
apparently  with  equally  satisfactorily  results,  the  arrangement  for  blowing 
through  the  ether  is  dispensed  with ;  a  simple  flask  being  emploj'ed  contain- 
ing a  rubber  cork  fitted  with  a  glass  tube  whose  lower  end  is  even  with  the 
lower  end  of  the  rubber  stopper.  To  the  upper  end  of  this  a  glass  tube  is 
attached  which  in  turn  is  attached  to  the  rectal  tube  by  means  of  an  inter- 
vening glass  tube.  Some  surgeons  prefer  to  have  this  attachment  made  by 
means  of  an  intervening  rubber  tube  which  is  fitted  with  a  stopcock  so  that 
the  flow  of  the  ether  fumes  may  be  interrupted  at  any  time.  The  flask  con- 
taining the  ether  is  then  immersed  in  a  water-bath  at  a  temperature  of  105 
degrees  F.,  which  will  cause  ether  to  evaporate  with  sufficient  rapidity  to 
bring  about  the  anesthesia.  In  case  the  amount  evaporated  is  not  sufficient, 
the  temperature  may  be  increased.  If  the  evaporation  is  too  rapid,  the  flask 
may  be  raised  out  of  the  water-bath  either  partly  or  completely  until  it  again 
becomes  desirable  to  increase  the  amount  of  ether  fumes. 

The  procedure  is  so  simple  that  any  one  who  has  seen  it  applied  once 
can  readily  administer  ether  in  this  way,  but  it  seems  worth  while  to  be  explicit 
in  a  description  because  it  has  not  as  yet  received  practical  application  to  a 
sufficient  extent  to  become  familiar  by  demonstration.  By  substituting  a 
good-sized  thermos  bottle  for  the  container  of  the  warm  water,  with  a  rubber 
cork  that  fits  closely  around  the  upper  end  of  the  bottle  containing  the  ether, 
the  apparatus  can  be  still  further  improved  because  the  water  will  then  main- 
tain a  fairly  uniform  temperature  throughout  the  operation  and  the  slight 
decrease  in  temperature  will  be  rather  an  advantage  than  otherwise.  The 
method  has  not  found  many  followers. 


74  GENERAL  SURGICAL  CONSIDERATIONS 

GENERAL  RULES  REGARDING  INCISIONS 

Rules  ignored  in  malignant  growths.  In  making  incisions  it  is  important 
in  tlie  first  place  to  bear  in  mind  the  fact  tliat  in  operating  for  the  removal 
of  malignant  growths  all  rules  concerning  the  direction  and  extent  of  incisions 
may  be  disregarded  if  by  regarding  them  there  is  the  slightest  danger  of  leav- 
ing any  portion  of  the  growth  in  the  body  of  the  patient.  In  a  very  large 
proportion  of  patients  that  have  come  under  care  in  an  inoperable  and  hope- 
less condition  from  the  recurrence  of  a  malignant  growth,  some  timid  surgeon 
has  made  the  first  removal  wdth  a  view  of  obtaining  a  satisfactory  cosmetic 
result.  Had  the  first  excision  been  bold  Avithout  regard  to  the  necessary 
deformity,  many  of  these  patients  would  have  been  permanently  relieved  by 
the  first  operation.  For  this  reason  it  seems  wise  to  insist  at  this  point  on  dis- 
regarding cosmetic  conditions  absolutely  when  they  interfere  to  the  slightest 
degree  with  thoroughness  in  dealing  with  the  removal  of  malignant  growths. 

In  all  other  cases  there  are  nine  conditions  to  be  borne  in  mind. 

Nine  rules  of  guidance.  1.  The  skin  incision  should  be  made  in  a  manner 
to  correspond  with  the  natural  folds  in  order  to  be  as  little  apparent  as  possible 
after  healing  has  taken  place.  Careful  inspection  of  the  surface  markings 
of  the  skin  will  always  suggest  position  and  direction  of  the  incision,  so  as  to 
result  in  the  least  degree  of  deformity  for  the  amount  of  disturbance  required 
by  the  operation. 

2.  The  underlying  anatomical  structures  must  be  considered.  Of  these 
the  important  nerves  and  the  large  blood  vessels  are  to  be  heeded  •,  the  former 
because  if  united  after  having  been  once  severed,  ideal  results  are  not  usually 
obtained ;  the  latter  because  of  the  danger  of  post-operative  gangrene  or  edema 
in  the  extremities  and  of  serious  cerebral  disturbances  in  case  of  section  of 
the  large  vessels  in  the  neck. 

3.  At  points  where  muscles,  aponeuroses  or  fascia  are  needed  to  support 
important  parts,  as  in  the  abdominal  wall,  it  is  wise  to  plan  all  incisions  so 
that  the  object  of  the  operation  may  be  accomplished  and  the  structures  sepa- 
rated so  as  to  secure  a  fair  amount  of  space  for  performing  the  various  steps 
of  the  operation  and  still  to  have  muscles  and  fascia  separated  or  split  rather 
than  cut  at  right  angles,  in  order  that  when  the  operation  itself  has  been  com- 
pleted these  separations  or  splittings  may  be  repaired  and  thus  the  conditions 
at  the  conclusion  of  the  operation,  so  far  as  the  tissues  are  concerned  through 
which  it  was  necessary  to  secure  entrance,  may  be  as  nearly  as  possible  the 
same  as  they  were  at  the  beginning  of  the  work. 

This  plan  has  the  further  advantage  of  making  it  possible  to  avoid  injuring 
nerves  and  blood  vessels  of  importance  in  the  region  of  the  operation  because 
these  usually  lie  in  the  direction  of  and  parallel  to  the  muscles. 

4.  In  portions  of  the  body  in  which  the  surface  is  exposed,  as  in  the 
neck  and  face,  symmetry  should  be  attained  as  much  as  possible.  In  many 
instances,  as  in  operations  upon  the  forehead,  the  nose,  the  lips,  the  chin  or 
the  neck,  a  one-sided  incision  will  result  in  much  deformity  when  an  incision 
extending  over  both  sides  resulting  in  an  equal  amount  of  exposure  of  under- 
lying tissues,  will  cause  but  a  slight  amount  of  deformity. 

5.  It  is  important  to  bear  in  mind  the  occupation  of  the  patient.  Future 
"usefulness  may  be  of  so  much  greater  value  to  the  patient  in  many  instances 
than  personal  appearance  that  the  latter  may  be  practically  disregarded, 
while  in  other  cases  quite  the  opposite  may  be  the  case. 

6.  It  is  important  to  plan  incisions  so  that  they  will  not  become  pain- 
ful later,  because  of  pressure  or  because  of  the  motion  of  contiguous  joints. 

7.  "Wherever  it  is  possible  to  hide  scars  under  the  natural  covering  of  hair, 
as  in  the  region  of  the  eyebrows  or  the  male  beard,  it  is  well  to  take  advantage 
of  these  structures. 


GENERAL  SURGICAL  CONSIDERATIONS 


75 


Anteeioe  Incisional  Lines. 


76 


GENERAL  SURGICAL  CONSIDERATIONS 


Anterior  Abdominal  Incisional  Lines. 


GENERAL  SURGICAL  CONSIDERATIONS 


77 


Posterior  Incisional  Lines. 


78  GENERAL  SURGICAL  CONSIDERATIONS 

8.  But  while  considering  all  of  these  features,  it  is  important  not  to 
lose  sight  of  the  fact  that  the  incision  must  be  so  planned  as  to  expose  the 
diseased  structures  to  be  treated  during  the  surgical  operation  so  that  this 
treatment  can  be  carried  out  to  the  best  advantage  of  the  patient. 

9.  In  a  general  way  the  incision  should  be  made  in  the  direction  of  the 
muscles,  nerves  and  blood  vessels. 

An  exceptional  rule.  There  is  one  exception  to  this  last  rule,  viz.,  in 
exploring  for  needles  or  other  thin  objects  that  are  buried  in  the  tissues  and 
that  have  been  located  by  the  use  of  skiagrams.  It  is  practically  impos- 
sible to  find  these  foreign  bodies  unless  the  incision  is  made  at  right-angles 
to  the  object.  Of  course,  if  the  needle  lies  parallel  to  arteries  and  nerves  then 
the  transverse  incision  will  also  be  at  right-angles  to  these  structures,  which 
must  be  carefuly  found  and  retracted  to  one  end  of  the  incision  while  the 
latter  penetrates  into  the  depth  beyond. 

We  have  repeatedly  been  able  to  locate  needles  buried  in  the  deep  tissues 
in  a  few  moments  in  cases  in  which  a  search  of  more  than  an  hour  had 
failed  to  locate  the  foreign  body  previously,  because  this  was  attempted 
through  an  incision  parallel  or  nearly  parallel  to  the  foreign  body.  * 

The  only  structures  that  need  to  be  considered  in  these  instances  are  the 
nerves  and  the  blood  vessels  in  case  the  latter  are  of  any  considerable  size, 
and  also  the  tendons.  Muscle,  fat,  skin  and  fascia  may  be  severed  and  reunited 
with  catgut  sutures. 

Surface  incisional  lines  of  choice.  The  choice  of  location  and  direction 
for  these  incisions  has  been  carefullj^  worked  out  by  many  surgeons  and 
anatomists.  The  scheme  developed  by  Professor  Sanger,  slightly  modified 
to  suit  our  clinical  work,  has  seemed  most  simple  and  still  sufficiently  compre- 
hensive to  be  entirely  satisfactory. 

The  accompanying  figures  represent  the  lines  on  the  anterior  and  posterior 
surfaces  of  the  body. 

There  is  a  marked  advantage  in  choosing  these  lines  not  only  from  the 
fact  that  one  can  obtain  convenient  access  to  the  underlying  structures, 
but  also  that  in  these  locations  one  can  safely  make  the  incisions  sufficiently 
large  to  obtain  a  free  view  of  the  tissues  to  be  considered  in  the  operation. 
It  is  a  mistake  to  perform  operations  through  incisions  which  are  too  small, 
for  fear  of  producing  deformity  from  making  a  larger  external  wound,  because 
if  these  locations  are  chosen  in  a  position  and  direction  which  is  anatomi- 
cally correct,  there  is  no  danger  of  obtaining  ugly  scars  as  the  underlying 
muscles  will  not  distort  the  resulting  cicatrix,  and  these  wounds  heal  with- 
out leaving  any  considerable  deformity.  In  fact  in  many  instances  it  is 
difficult  to  recognize  the  scar  after  a  few  years. 

Separation  of  deep  structures.  It  is,  however,  quite  as  necessary  to  study 
the  best  manner  of  separating  the  deeper  tissues  as  it  is  to  choose  properly 
the  position  and  direction  of  the  external  wound.  Here  again  it  is  important, 
■vv^henever  possible,  to  separate  the  muscles  instead  of  cutting  them.  Small 
arteries  and  veins  may  be  disregarded.  Large  blood  vessels  should  be  pro- 
tected, not  only  against  direct  injury  but  also  from  crushing  by  the  use  of 
retractors,  because  this  undoubtedly  often  causes  phlebitis  or  thrombosis 
after  surgical  operations. 

The  special  details  concerninsr  incisions  will  be  fully  considered  in  con- 
nection with  each  individual  operation. 

HEMOSTASIS 

Conserve  the  blood.  It  is  important  to  secure  prompt  and  efficient  hemo- 
stasis  during  surgical  work,  because  there  is  a  direct  relation  between  the 
degree  of  shock  and  the  amount  of  blood  lost  by  the  patient.    Whenever  it  is 


GENERAL  SURGICAL  CONSIDERATIONS  79 

possible  to  isolate  blood  vessels,  to  clamp  them  doubly  by  applying  two  pairs 
of  hemostatic  forceps,  to  cut  between  these  and  to  ligate  the  proximal  end, 
one  has  obtained  ideal  conditions. 

In  many  operations  this  plan  can  be  carried  out  to  such  an  extent  as  to 
practically  prevent  loss  of  blood  altogether.  Ordinarily,  this  is  of  no  impor- 
tance in  itself,  because  most  patients  can  bear  the  loss  of  a  fair  amount  of 
blood  without  harm ;  but  hemostasis  also  keeps  the  tissues  clearly  exposed  so 
that  the  anatomical  relations  can  be  kept  perfectly  in  view  constantly  during 
the  operation.  This  not  only  facilitates  the  work,  but  makes  it  possible  to 
suture  the  tissues  with  all  of  the  structures  in  their  normal  relations,  leaving 
the  completed  operation  more  perfect  than  it  would  be  had  the  field  been 
constantly  obscured  by  being  saturated  with  blood. 

Some  surgeons  have  carried  this  idea  to  an  absurd  conclusion.  They  have 
insisted  upon  catching  even  the  smallest  vessels  with  hemostatic  forceps 
and  ligating  each  vessel  separately,  thus  consuming  several  times  as  much 
time  as  necessary  in  performing  the  operation.  AYe  have  seen  a  patient  kept 
under  an  anesthetic  for  a  period  of  four  hours,  at  least  three  of  such  hours 
being  consumed  in  ligating  small  vessels  which  would  have  ceased  bleeding 
within  a  few  moments  without  causing  any  harm  to  the  patient  whatever. 

On  the  other  hand  it  is  quite  as  bad  to  be  reckless  about  the  loss  of 
blood,  for  such  disregard  is  certain  to  result  in  the  death  of  a  patient  occa- 
sionally. 

It  is  wise  to  use  strong-jawed  hemostatic  forceps  which  will  crush  the 
end  of  the  blood  vessels  of  medium  and  small  size.  These  may  be  left  in 
place  until  the  operation  has  been  completed  when  only  the  large  vessels  need 
to  be  ligated,  the  crushing  having  permanently  closed  the  smaller  vessels. 

It  is  well  to  bear  in  mind  that  the  surface  of  the  wound  should  not  be 
rubbed  with  sponges  or  gauze  pads  after  these  forceps  have  been  removed, 
because  this  often  opens  up  blood  vessels  which  would  otherwise  remain 
closed  permanently. 

Torsion  of  blood  vessels  for  hemostasis.  Before  it  was  possible  always  to 
obtain  perfectly  sterile,  absorbable  ligatures  the  method  of  grasping  blood 
vessels  with  hemostatic  forceps  and  twisting  them  in  order  to  permanently 
occlude  the  bleeding  point  had  obtained  many  adherents.  It  is  reasonable 
that  this  should  be  so.  Many  surgeons  applied  this  method  to  vessels  as  large 
as  the  brachial  or  popliteal  artery.  Although  this  can  be  done  safely  in  most 
cases,  it  would  be  foolish  to  make  use  of  this  method  in  any  of  the  larger 
vessels  at  the  present  time,  because  it  is  not  as  dependable  as  ligation,  and  the 
latter  is  quite  safe  always  and  has  no  disadvantages  over  the  former. 

Crushing  and  the  application  of  heat.  Several  years  ago  many  instruments 
were  invented  for  the  purpose  of  crushing  large  blood  vessels  with  an  enormous 
force  applied  to  the  jaws  of  the  forceps  by  means  of  levers  or  screw  arrange- 
ments. These  instruments  are  now  temporarily  obsolete,  but  they  are  cer- 
tain to  be  readvised  from  time  to  time,  although  there  is  no  longer  any  real 
need  because  of  the  fact  that  ligation  with  catgut  ligatures  is  more  convenient 
and  in  every  way  equally  satisfactory  and  somewhat  more  reliable  even  in 
the  hands  of  surgeons  who  use  the  crushing  forceps  with  the  greatest  care 
and  patience. 

Moreover  the  ligature  saves  time  because  the  crushing  forceps  must  be 
left  in  position  at  least  for  a  period  of  one  minute  in  order  to  make  their  use 
fairly  safe.  For  the  average  surgeon  these  powerful  crushing  forceps  are 
not  safe  because  he  will  not  exercise  the  necessary  care  in  applying  them, 
nor  patience  to  leave  in  place  the  necessary  length  of  time.  It  is  quite  a 
different  matter  from  the  use  of  the  strong- jawed  hemostatic  forceps  men- 
tioned above,  as  these  can  be  left  attached  to  the  smaller  blood  vessels  while 
the  operation  proceeds. 


80  GENERAL  SURGICAL  CONSIDERATIONS 

Heated  clamps.  Dowd  has  invented  a  clamp  containing  a  coil  of  platinum 
wire  for  the  purpose  of  heating  the  jaws  of  the  instrument  by  passing  a  cur- 
rent of  electricity  through  the  coil. 

The  clamp  is  applied  to  a  mass  of  tissue,  like  a  broad  ligament,  then 
its  jaws  are  isolated  from  the  surrounding  tissues  by  a  metal  shield  whose 
construction  makes  it  a  poor  conductor  of  heat,  then  a  current  of  electricity 
is  passed  through  the  forceps  sufficiently  strong  to  heat  the  blades  so  that 
the  stump  will  be  thoroughly  boiled  for  twenty  to  forty  seconds.  The  cur- 
rent is  then  turned  off  and  the  stump  is  cut  beyond  the  clamps  when  the 
latter  are  removed.  In  order  to  prevent  the  jaws  of  these  clamps  from 
adhering  to  the  cauterized  stumps  they  are  thoroughly  covered  with  sterile 
olive  oil  before  being  applied. 

The  method  is  perfectly  satisfactory,  but  it  seems  indicated  only  in  cases 
in  which  the  portion  beyond  the  pedicle  contains  malignant  tissue,  as,  for 
instance,  removal  of  the  uterus  and  ovaries,  for  the  cure  of  carcinoma  of 
the  uterus.  In  ordinary  operations  the  method  is  in  no  way  to  be  preferred 
to  the  catgut  ligature. 

In  the  removal  of  organs  containing  malignant  growths  the  cauteriza- 
tion of  the  stump  may  prevent  recurrence  where  there  may  be  invasion  extend- 
ing into  but  not  beyond  the  stump. 

LIGATURE  MATERIAL 

Catgut  ligature  the  best.  Catgut,  prepared  according  to  the  methods 
already  described,  is  an  ideal  ligature  material  because  it  has  great  tensile 
strength ;  is  absolutely  free  from  septic  germs  or  spores ;  is  thoroughly  filled 
with  minute  crystals  of  iodoform  which  remain  in  the  ligature  until  the  last 
portion  has  been  absorbed,  thus  preventing  the  ligature  or  the  stump  of  the 
vessel  from  becoming  a  culture  medium  for  micro-organisms  which  may  be 
present  in  the  circulation.  In  any  location  in  which  it  is  possible  for  pres- 
sure-necrosis to  occur,  with  subsequent  infection  due  to  local  conditions, 
it  is  wise  to  use  catgut  which  is  so  tine  that  pressure-necrosis  is  not  fearerl 
because  of  the  fact  that  the  fine  catgut  lacks  tensile  strength  enough  to  crush 
the  tissues  sufficiently  to  cause  their  death. 

In  ligating  very  large  vessels  it  is  well  to  leave  a  sufficient  portion  of 
the  vessels  projectirig  beyond  the  point  at  which  the  ligature  has  been  applied 
so  as  to  prevent  slipping.  It  is  also  well  to  crush  the  wall  of  the  blood 
vessel  at  the  point  at  which  the  ligature  is  to  be  applied  by  the  use  of 
strong  hemostatic  forceps,  as  this  will  crush  all  of  the  soft  tissues  and  intima 
out  of  the  blood-vessel  wall  and  leave  in  place  only  the  connective  tissue  por- 
tion. The  same  principle  applies  to  the  ligation  of  pedicles  of  considerable  size, 
such  as  the  pedicle  of  an  ovarian  cyst,  or  the  cecal  end  of  the  vermiform 
appendix. 

SEARING  OF  BLEEDING  SURFACES 

Occasionally  there  is  a  constant  oozing  of  blood  from  the  surface  of  a 
wound,  which  does  not  subside  under  pressure  with  hot  moist  gauze  sponges. 
In  these  cases  it  is  sometimes  well  to  hold  a  red  or  white  hot  cauterv  iron 
near  the  surface,  without  actually  touching  it.  This  method  is  especiallv  use- 
ful in  oozing  from  bone  surfaces.  Here  the  same  result  may  be  accomplishedjj 
by  an  apparatus  commonly  used  by  artists  in  making  burnt  woodwork. 

It  is  not  often  necessary  to  resort  to  this  method.  The  application  oi 
a  gauze  pad  wrung  out  of  very  hot,  or  even  boiling  water  will  usually  accom-i 
plish  the  same  end  in  a  more  convenient  manner.     In  using  hot  moist  pads 


'  GENERAL  SUEGICAL  CONSIDERATIONS  81 

it  is  important  to  leave  them  in  place  without  change  for  several  minutes  at  a 
time.  If  applied  to  the  oozing  surface  with  pressure  the  effect  is  more  satis- 
factory. 

APPLICATION  OF  SUTURES 

It  is  often  necessary  to  apply  catgut  sutures  to  bleeding  surfaces  en  masse 
because  the  bleeding  may  be  so  diffuse  that  it  is  quite  impossible  to  catch 
each  of  the  innumerable  small  vessels  separately.  In  these  cases  a  suture 
is  applied  around  areas  and  tied  in  the  form  of  a  purse-string,  or  two  opposing 
surfaces  are  sutured  together,  the  pressure  thus  caused  upon  both  surfaces 
preventing  the  diffuse  hemorrhage.  If  the  wound  is  near  some  of  the  larger 
blood-vessels  it  is,  of  course,  important  not  to  injure  these  structures  in  passing 
the  sutures  through  the  deep  tissues. 

EXTERNAL  PRESSURE 

In  many  cases  in  which  large  wound  surfaces  are  produced,  as,  for  instance, 
in  excision  of  the  breast,  it  is  important  to  apply  large  pads  of  cotton  over 
the  surface  when  the  wound  is  dressed,  and  to  hold  these  in  place  by  the 
application  of  soft,  gauze,  rolled  bandages.  The  uniform  pressure  will  result 
in  stoppage  of  oozing  from  the  surfaces  of  these  large  flaps  which  may  be 
but  very  slight  from  any  one  point,  but  which  would  result  in  the  loss  of  a 
large  amount  of  blood  from  the  entire  surface,  were  this  not  prevented  by 
the  careful  application  of  pressure  by  a  properly  adjusted  dressing. 

POSITION  OF  THE  EXTREMITIES 

If  there  is  any  difficulty  in  controlling  hemorrhage  in  the  extremities 
this  can  always  be  accomplished  by  elevating  the  part  to  its  fullest  extent 
and  applying  pressure  at  the  point  of  bleeding  until  the  blood-vessel  can  be 
ligated  in  the  wound,  or  above  it.  This  is  true  especially  in  the  troublesome 
hemorrhage  due  to  injury  to  the  plantar  or  the  palmar  arch.  We  have 
encountered  such  cases  in  which  recurrent  hemorrhages  have  greatly  dis- 
tressed both  physician  and  patient,  but  where  permanent  relief  was  at  once 
obtained  upon  elevating  the  extremity,  applying  a  small  compress  and  keep- 
ing the  part  raised  for  a  week  or  ten  days.  It  is,  of  course,  important  not 
to  permit  these  patients  to  lower  the  extremity  too  soon,  because  the  pressure 
ensuing  is  often  sufficient  to  force  out  the  occluding  blood  clot  unless  it  has 
had  time  to  become  fairly  well  fixed. 

INJURIES  TO  THE  WALLS  OF  BLOOD  VESSELS  DURING 

OPERATIONS 

Occasionally  a  portion  of  a  blood-vessel  wall  is  intentionally  reraoved 
during  an  operation,  but  much  more  commonly  this  happens  as  an  accident, 
especially  to  the  large  veins  in  operations  upon  the  neck,  the  axilla  or  the 
groin.  In  these  instances  it  is  well  to  carefully  compress  the  vessel  above 
and  below  the  injured  point.  If  the  opening  is  very  small  it  is  often  possible 
to  grasp  it  with  one  or  two  hemostatic  forceps  with  rounded  ends  and  to 
apply  a  fine,  strong  ligature.  Usually  this  Avill  close  the  opening  and  the 
result  will  be  precisely  the  same  as  after  ligating  a  lateral  branch  of  a  large 
vein.  Under  such  circumstances  it  is  important  to  apply  the  dressings  very 
snugly  in  order  to  support  the  ligature  in  case  of  increased  intra-venous 
pressure  due  to  vomiting  after  the  operation. 

Repair  of  blood  vessels.  Should  the  opening  be  too  large  to  be  closed  hy 
this  method  it  may  be  sutured  by  means  of  a  very  fine  needle  threaded  with 
smooth  catgut.  It  is  best  to  use  "the  catgut  double  because  the  double  strand 
will  more  perfectly  fill  the  needle  punctures.    It  is  well  to  wait  a  few  minutes 


82  GENERAL  SURGICAL  CONSIDERATIONS 

after  the  sutures  have  been  applied  before  removing  the  pressure  at  either 
side  of  the  wound,  in  order  to  permit  the  needle  punctures  to  become  adherent 
to  the  sutures.  The  distal  compression  should  be  released  first,  and  a  little 
later  that  on  the  proximal  side.  The  sutures  are  applied  according  to  a 
method  later  to  be  illustrated  in  connection  with  intestinal  sutures.  It  seems 
best  to  insert  the  sutures  so  that  they  will  not  penetrate  quite  into  the  lumen 
of  the  blood  vessels  for  fear  of  producing  thrombosis. 

At  the  suggestion  of  McAlester,  Guthrie  has  introduced  human  hair  as 
a  substitute  for  catgut  and  silk  in  suturing  blood-vessel  walls,  and  his  plan 
seems  to  be  worth  imitating.  He  uses  a  number  12,  14  or  16  cambric  needle 
which  can  be  obtained  at  dry-goods  stores,  choosing  the  small-eyed  variety. 
He  threads  this  with  a  long  human  hair  and  sutures  as  described  above.  The 
hair  is  sterilized  by  boiling  in  paraffin  oil.  This  suture  is  very  fine  and  still 
quite  strong  enough. 

If  the  vessel  has  been  cut  off  entirely  it  may  be  united  by  these  sutures, 
or  the  two  ends  may  be  threaded  upon  magnesium  rings  and  these  can  be 
forced  against  each  other  by  means  of  fine,  strong,  catgut  sutures. 

In  all  of  these  operations  it  is  important  to  exercise  great  care  not  to 
injure  the  intima  in  compressing  the  vessel  above  and  below  the  wound. 
Various  forceps  have  been  invented  for  this  purpose  and  metallic  bands  have 
been  recommended  by  Halstead  and  by  Matas.  Many  surgeons  apply  tem- 
porary ligatures  wiiile  others  always  have  the  bleeding  controlled  by  digital 
pressure. 

So  long  as  the  vessel  walls,  and  especially  the  intima,  are  not  injured  it 
does  not  matter  what  method  is  chosen. 

In  all  operations  near  large  veins  it  is  of  the  utmost  importance  to  exercise 
great  caution  to  prevent  tearing  these  structures,  as  the  walls  of  even  very 
large  veins  are  frequently  delicate  and  consequently  very  easily  ruptured. 
It  is  best  first  to  expose  these  veins  and  then  to  work  away  from  them. 

VESSELS  SEVERED  NEAR  THEIR  ORIGIN 

Especial  care  must  be  followed  in  ligating  vessels  which  have  been  severed 
near  their  origin.  A  careless  assistant  can  easily  pull  the  remaining  portion 
of  a  vein  out  of  the  side  of  the  large  vein  into  which  it  empties,  thus  leaving 
a  lateral  defect  in  the  latter  which  can  often  be  repaired  only  with  difficulty 
by  one  of  the  methods  just  described.  To  make  things  worse  he  may  make 
frantic  efforts  to  stop  the  resulting  hemorrhage  by  wildly  applying  forceps 
to  the  side  of  the  vein,  usually  either  increasing  the  original  defect  or  making 
new  ones.  In  these  accidents  it  is  well  always  to  remember  that  such  an 
opening  can  be  closed  at  once,  without  the  use  of  any  force,  by  simply  placing 
the  end  of  a  finger  over  the  opening.  Then  the  vessel  can  be  digitally  com- 
pressed above  and  below  the  opening  and  forceps  can  be  applied  at  leisure, 
or  the  vent  may  be  closed  with  sutures. 

After  applying  forceps  to  vessels  near  their  origin  it  is  well  always  to 
ligate  at  once  in  order  to  prevent  harm  from  traction  upon  the  handles  of 
the  forceDS. 

SUTURING  OF  DEEP  WOUNDS 

It  is  important  in  all  deep  wounds  to  have  the  surfaces  absolutely  in 
apposition  in  order  to  prevent  the  formation  of  spaces  in  which  quantities  of 
blood  and  serum  may  accumulate. 

In  most  instances  these  accumulations  will  absorb  or  become  organized, 
but  there  is  always  a  possibility  of  infection  through  the  circulation  or  a 
slight  infection  at  the  time  of  operation,  which  would  not  be  sufficient  to 
cause  a  local  disturbance  if  no  good   culture  medium  were  provided,   and 


GENERAL  SUEGICAL  CONSIDERATIONS  83 

which  may  cause  some  delay  in  the  ultimate  wound-healing  in  case  spaces 
are  left  between  the  wound  surfaces. 

For  this  reason  it  is  well  to  unite  the  deep  layers  by  means  of  fine,  catgut 
sutures  because  union  takes  place  within  a  few  hours  and  then  the  support 
will  no  longer  be  needed. 

Caution  against  tight  sutures.  It  is  important  to  bear  in  mind,  however, 
that  nothing  is  more  favorable  for  the  location  of  infection  than  necrosed 
areas  due  to  the  application  of  sutures  drawn  too  tightly.  It  is  consequently 
best  to  draw  these  deep,  buried,  catgut  sutures  only  just  sufficiently  firm  to 
bring  the  surfaces  together,  but  not  firmly  enough  to  cause  pressure-necrosis. 

By  using  for  this  purpose  fine  catgut  prepared  by  any  one  of  the  methods 
already  described,  preserved  in  the  iodoform-ether-alcohol  mixture,  the  results 
are  most  satisfactory. 

All  unabsorbable  suture  material,  like  silk,  silkworm  gut,  linen,  silver, 
aluminum  or  bronze  wire  is  to  be  condemned  for  this  purpose.  It  has  no 
advantage  over  the  catgut  and  has  the  very  serious  disadvantage  of  causing 
long-continued  irritation,  ultimately  necessitating  a  removal  of  the  suture  in 
many  cases. 

The  material  least  harmful  among  these  is  very  fine  silk  because  this  will 
in  time  become  absorbed. 

SUTURING  OF  SUPERFICIAL  WOUNDS 

In  closing  superficial  wounds  two  kinds  of  sutures  must  be  considered, 
viz.,  those  that  are  used  for  the  purpose  of  coaptating  the  wound  edges,  and 
those  that  are  used  for  the  purpose  of  overcoming  tension  or  for  protecting 
the  wound  against  sudden  strain,  as  in  case  of  sneezing,  coughing  or  vomiting. 
Many  wounds  are  located  so  that  there  is  no  tension  at  all  and  in  these  only 
the  coaptation  sutures  are  needed. 

TENSION  SUTURES 

Where  there  is  severe  tension  it  is  important  to  study  the  degree  thereof 
and  the  direction,  and  to  adjust  the  sutures  to  the  best  advantage  of  the 
existing  conditions.  For  this  purpose  strong  silk  or  wire  sutures  are  most 
suitable.  The  ends  which  rest  against  the  skin  may  be  attached  to  lead 
plates  or  pledgets  of  gauze.  Since  the  introduction  of  the  Thiersch  method 
of  skin-grafting,  however,  the  tension  suture  is  employed  to  a  much  slighter 
extent  than  formerly,  because  in  most  cases  it  is  better  to  leave  a  surface 
to  be  covered  by  skin-grafts  than  to  put  too  much  tension  on  the  flaps. 

In  all  cases  in  which  there  is  tension  it  is  well  to  leave  the  edges  a  few 
millimeters  apart  at  the  time  the  wound  is  closed,  as  this  will  enable  the 
lymph  to  escape  from  the  edges  of  the  wound  thus  preventing  the  edema 
which  is  certain  to  occur  if  the  wound  edges  are  closely  sutured,  and  this 
edema  favors  necrosis  of  the  flap.  This  is  especially  to  be  borne  in  mind 
in  all  cases  in  which  there  is  arterio-sclerosis,  and  still  more  in  those  suffering 
from  diabetes. 

Wherever  it  is  possible  to  plan  an  operation  so  that  there  Avill  be  no 
tension  this  should  be  done,  and  in  no  case  should  sutures  be  tied  tightly 
enough  to  cause  pressure-necrosis. 

PRINCIPLES  OF  SUPERFICIAL  SUTURES 

In  suturing  superficial  wounds  certain  principles  must  be  observed  with- 
out regard  to  suture  material. 

1.  Sutures  should  be  drawn  just  tightly  enough  to  bring  the  wound 
edges  together,  but  not  sufficiently  tight  to  cause  pressure-necrosis. 


84  GENERAL  SURGICAL  CONSIDERATIONS 

2.  Allowance  should  be  made  for  the  edema  which  always  occurs  a  day 
or  two  after  the  operation. 

3.  The  bite  of  the  needle  should  be  equal  on  both  sides  of  the  incision, 
both  as  to  depth  and  length  of  stitch. 

4.  The  tension  should  be  disposed  of  by  one  set  of  sutures,  the  coapta- 
tion by  another  which  may,  however,  also  be  accomplished  by  making  one 
deep  and  one  superficial  stitch  alternately. 

METAL  CLIPS 

Many  different  metal  clips  have  been  invented  and  some  of  them  are 
quite  as  satisfactory  as  the  various  sutures  which  have  been  described;  they 
are,  however,  much  more  expensive  and  this  element  must  be  considered,  espe- 
cially in  hospital  work.  Results  are  no  better  than  with  sutures,  consequently 
their  employment  must  remain  entirely  a  matter  of  personal  choice. 

NON-ABSORBABLE  SUTURE  MATERIAL 

The  most  useful  suture  materials  of  this  class  consist  of  silk,  linen, 
horsehair,  silkworm  gut,  silver,  bronze,  or  aluminum  wire.  The  first,  second 
and  third  may  be  impregnated  v\'ith  celloidin  or  with  paraffin  to  prevent 
the  entrance  of  pus.  The  others  are  all  impermeable.  All  of  these  materials 
may  be  used  both  as  superficial,  removable  sutures,  or  they  may  be  buried, 
but  in  the  latter  case  they  are  certain  to  cause  much  annoyance  both  to 
the  surgeon  and  to  the  patient,  because  in  the  event  of  infection  they  will 
later  have  to  be  removed  and  usually  the  patient  will  have  this  service 
performed  not  by  the  surgeon  Avho  applied  the  sutures  originally,  but  bj'' 
some  one  who  never  uses  unabsorbable  buried  sutures,  or  by  another  who 
has  for  some  time  abandoned  this  practice. 

If  applied  as  buried  sutures  it  is  important  not  to  include  muscles  in 
the  bite  of  the  suture,  as  the  contraction  of  the  muscles  is  very  likely  to 
cause  these  unabsorbable  sutures  to  act  as  irritating  foreign  bodies. 

Each  of  these  materials  has  its  advocates  because  of  some  especial  virtue, 
such  as  pliability,  ease  of  application,  non-absorption  of  wound  secretion, 
slight  antiseptic  qualities  as  with  silver  wire,  slight  elasticity,  as  in  case  of 
horsehair,  cheapness,  as  in  case  of  silk,  linen  and  horsehair. 

As  a  matter  of  fact  if  applied  without  tension  all  of  these  materials  are 
very  satisfactory.  The  various  conditions  under  which  one  or  the  other  is 
preferable  will  be  mentioned  in  connection  with  the  particular  operations. 

ABSORBABLE  SUTURE  MATERIAL 

Catgut  is  the  only  absorbable  suture  material  that  needs  to  be  considered 
because,  if  properly  prepared,  it  fills  every  requirement.  It  is  more  expen- 
sive than  silk,  linen  and  horsehair,  and  should  consequently  not  be  used 
where  these  will  serve  the  same  purpose.  It  is  quite  as  satisfactory  in  every 
particular  as  kangaroo  tendon,  and  vastly  superior  in  many  respects,  and 
should  therefore  displace  the  latter  entirely. 

If  the  methods  of  preparation  and  preservation  described  heretofore  are 
carefully  carried  out  this  material  is  absolutely  reliable  both  as  regards 
tensile  strength,  time  required  for  absorption  and  absolute  asepsis.  These 
methods  are  moreover  so  simple  that  any  honest  person  can  have  perfect 
results  and  there  are  many  manufacturers  who  supply  the  catgut  prepared 
so  that  it  can  be  used  without  any  fear  of  infection  from  this  source. 


I 


G-ENEHAL  SURGICAL  CONSIDERATIONS  85 

AFTER-TREATMENT  OF  ASEPTIC  WOUNDS 

Don't  meddle.  It  is  most  important  to  bear  in  mind  that  the  less  one 
meddles  with  aseptic  wounds  after  they  have  been  carefullr  sutured  and 
dressed,  the  more  certain  one  can  be  of  obtaining  primary  union.  If  the 
sutures  have  not  been  drawn  too  tightly  there  will  be  no  pressure-necrosis 
and  consequently  the  staphylococci  which  are  always  present  in  the  skin 
will  not  find  any  culture  medium.  It  is  well  to  dress  the  wound  on  the 
fifth  to  the  seventh  day,  being  careful  not  to  pull  the  united  wound  edges 
apart  by  rough  handling.  Then  it  is  well  to  paint  the  line  of  suture  with 
compound  tincture  of  iodine  and  remove  the  superficial  sutures,  then  once 
more  paint  the  surface  with  the  same  solution,  and  reapply  an  aseptic  dress- 
ing, leaving  the  deep  sutures  to  be  removed  later,  as  indicated  in  connection 
with  the  various  operations.  The  tincture  of  iodine  seems  to  obliterate  the 
little  suture  marks. 

Support  by  strapping.  The  deep  sutures  removed  it  is  well  to  apply  a  rubber 
adhesive  plaster  to  each  side  of  the  wound  and  about  two  inches  away  from, 
its  edge.  These  straps  should  contain  a  number  of  tapes,  about  one  for 
every  four  cm.  of  length  of  wound.  These  straps  are. applied  and  left  untied 
for  a  day  or  two  in  order  to  secure  perfect  attachment  to  the  skin,  then  the 
tapes,  which  should  be  so  arranged  as  to  be  opposite  each  other,  should  be 
tied  sufficiently  firm  to  remove  all  tension  from  the  wound  itself.  In  this  way 
it  is  possible  to  obliterate  the  scar  almost  completely.  Unless  this  precau- 
tion is  taken  the  wound  frequently  becomes  drawn  out  into  an  ugly,  broad, 
white,  disfiguring  mark. 

Unless  the  sutures  are  tied  loosely  each  one  leaves  a  transverse  mark 
across  the  wound,  which  is  also  likely  to  be  very  unsightly. 

Occlusive  and  antiseptic  applications.  A'^arious  substances  have  been  rec- 
ommended for  application  to  the  wound  for  the  purpose  of  preserving  asepsis 
and  preventing  the  formation  of  ugly  scars ;  of  these  flexible  collodion  and 
concentrated  tincture  of  benzoin  are  the  best.  Of  the  various  powders  those 
that  are  non-irritating  and  odorless,  and  contain  some  form  of  iodine,  are 
the  best.  Most  of  these  are  made  under  some  patent,  and  as  wounds  heal 
quite  as  perfectly  without  their  use  it  does  not  seem  proper  or  necessary  to 
mention  them  specifically. 

Avoid  any  unnecessary  manipulations.  It  is  very  important  never  to  crush 
or  manipulate  wounds  at  the  time  of  dressing.  Inexperienced  assistants 
seem  to  have  an  insane  desire  to  feel  of  wounds  and  there  can  be  no  doubt 
that  the  gratification  of  this  desire  results  in  the  infection  of  many  wounds 
which  would  otherwise  heal  by  first  intention. 

Removal  of  sutures.  In  removing  the  superficial  sutures  great  care  should 
be  exercised  not  to  separate  the  delicately-united  wound-edges.  It  is  much 
better  not  to  touch  these  sutures  for  two  weeks  after  they  have  been  applied 
than  to  disturb  the  edges  in  the  least  while  removing  them  early  in  order 
to  prevent  the  stitch  marks.  A  careful  assistant,  with  reasonable  patience 
can,  however,  remove  these  superficial  sutures  with  proper  forceps  and  scissors 
without  fear  of  causing  this  disturbance. 

AFTER-TREATMENT  OF  PRIMARILY  SEPTIC  WOUNDS 

Every  surgeon  encounters  many  wounds  that  are  primarily  septic  in  cases 
which  come  to  him  because  of  the  presence  of  a  septic  condition. 
In  these  the  following  results  must  be  obtained : 

1.  The  accumulation  of  septic  material  must  be  evacuated. 

2.  Provision  must  be  made  against  reaccumulation  of  septic  material. 

3.  Absorption  of  septic  material  must  be  prevented. 


86  GENERAL  SURGICAL  CONSIDERATIONS 

The  first  of  these  conditions  is  accomplished  by  free  incision,  which 
must  of  course  be  varied  according  to  the  character  and  the  location  of  the 
infection.  The  second  object  is  accomplished  by  the  use  of  drainage  tubes 
or  tampons,  which  must  again  vary  according  to  conditions,  and  this  will 
in  turn  accomplish  the  third  object.  These  steps  will  cause  the  lymph  stream 
to  pass  away  from  the  infected  tissues  carrying  with  it  the  septic  material 
which  is  deposited  upon  the  dressings.  Thus  the  infection  of  tissues  hitherto 
free  will  be  prevented  in  a  physiological  way.  In  the  meantime  if  the 
infection  is  in  an  extremity  venous  congestion  should  be  prevented  by  elevating 
the  part,  and  progress  of  the  infection  through  the  lymph  channels  should 
be  prevented  by  placing  the  part  of  the  body  affected  perfectly  at  rest. 

The  elimination  through  the  lymph  stream  can  be  stimulated  by  the 
application  of  warm,  moist  dressings.  It  is  possible  that  by  adding  mild, 
non-poisonous  antiseptics,  like  boric  acid  and  alcohol,  to  these  dressings  that 
they  will  further  aid  the  processes  of  disinfection.  Kahlenberg  has  demon- 
strated that  boric  acid  is  rapidly  absorbed  when  applied  in  aqueous  solution 
externally,  whether  in  sufficient  quantity  to  have  a  beneficial  effect  has  not 
been  proven  although  clinical  observation  seems  to  bear  out  this  idea. 

Later  on  the  healing  can  be  accelerated  by  stimulating  the  wound  surfaces 
by  the  application  of  compound  tincture  of  iodine,  or  two  to  ten  per  cent, 
solution  of  nitrate  of  silver,  or  any  one  of  a  number  of  other  substances.  In 
case  of  septic  cavities  the  application  later  on  of  Beck's  bismuth  paste, — one 
part  of  arsenic  free  bismuth  subnitrate  in  two  parts  of  vaseline, — is  followed 
by  excellent  results. 

This  should  be  applied  at  first  each  day  and  later  on  less  frequently,  and 
should  be  kept  in  contact  with  the  deep  surfaces  by  transfixing  the  external 
wound. 

AFTER-TREATMENT  OF  CLEAN  WOUNDS  BECOMING  INFECTED 

Prevention.  Of  course  benefit  must  come  chiefly  from  prevention,  and 
this  must  depend  largely  upon  the  organization  of  a  reasonable  system,  and 
in  this  system  every  person  must  fully  appreciate  the  fact  that  he  carries 
an  important  portion  of  the  responsibility.  In  this  the  permanency  of  service 
is  a  most  important  matter  so  far  as  the  assistants  are  concerned,  and  per- 
manency of  methods  is  equally  important,  chiefly  because  of  the  fact  that 
this  secures  conditions  in  which  possible  flaws  or  weak  points  are  known 
and  can  be  guarded  against,  and  because  any  neglect  in  carrying  out  the 
methods  can  be  more  readily  recognized  than  when  changeable  plans  are 
employed. 

Whenever  there  is  any  evidence  of  infection  occurring  in  a  wound  which 
was  primarily  clean  it  is  well  at  once  to  remove  several  sutures,  especially 
at  points  showing  redness,  and  to  apply  a  large,  hot,  moist,  antiseptic  dress- 
ing consisting  preferably  of  one  part  of  alcohol  and  two  parts  of  a  suturated 
aqueous  solution  of  boric  acid  to  the  surface,  and  to  cover  this  dressing  with 
some  impermeable  substance  like  gutta  percha  tissue  or  oiled  muslin.  These 
wounds  should  not  be  manipulated.  If  the  infection  does  not  subside  at  once 
then  the  wound  should  be  opened  a  little  further,  or  in  severe  cases  it  may 
become  necessary  to  open  the  wound  throughout. 

From  this  point  on  the  treatment  should  be  the  same  as  in  the  cases 
just  described.  Usually  the  infection,  however,  subsides  promptly  upon  taking 
the  first  step  mentioned  above.  In  each  case  the  cause  should  be  determined. 
It  is  usually  a  slight  error  in  technic  which  can  readily  be  corrected  to  the 
benefit  of  patients  operated  on  subsequently. 

Post- operative  rupture  of  wounds.  It  occasionally  happens  that  an  ab- 
dominal  wound   ruptures,    due    to    extreme   intra-abdominal   pressure   from 


1 


GENERAL  SURGICAL  CONSIDERATIONS  87 

excessive  coughing  or  vomiting,  or  during  gastric  lavage.  This  accident  can 
be  prevented  by  always  placing  a  sufficient  number  of  silkworm-gut  sutures 
in  the  wound  and  tying  each  with  a  surgical  tie  at  least  three  times.  It  is 
important  also  that  the  fascia  be  not  sutured  too  tightly  so  as  to  cause  pres- 
sure-necrosis and  thereby  weaken  one  of  the  strongest  structures  in  the 
abdominal  wall.  By  relieving  cough  with  sedatives,  and  vomiting  by  gastric 
lavage  after  giving  a  hypodermic  injection  of  one-fourth  grain  of  morphine 
one-half  hour  before  beginning  gastric  lavage,  the  primary  causes  of  rupture 
can  be  avoided.  It  is  also  well  to  spray  the  throat  well  with  4  per  cent, 
solution  of  cocaine  before  attempting  to  introduce  the  tube,  in  order  to 
obviate  retching  and  gagging. 

In  order  to  suture  a  wound  following  a  post-operative  rupture,  the  patient 
is  anesthetized,  the  abdominal  contents  replaced  gently,  and  silkworm-gut 
sutures  applied  through  all  layers  about  1.5  cm.  apart  along  the  entire  wound. 
No  catgut  or  other  sutures  should  be  used.  In  this  way  the  wound  will  heal 
kindly,  unless  the  peritoneum  has  been  infected  or  the  intestines  have  been 
exposed  too  long  or  too  severely.  The  mortality  of  post-operative  rupture 
is  from  20  to  30  per  cent. 

SURGICAL  INSTRUMENTS 

It  is  well  to  become  accustomed  to  the  use  of  as  few  instruments,  and 
of  as  simple  construction  as  possible,  as  in  this  manner  the  surgeon  becomes 
so  familiar  with  each  instrument  that  he  can  use  it  with  the  same  facility 
that  the  skilled  artisan  shows  in  the  use  of  his  tools.  This  enables  the  sur- 
geon to  reduce  the  time  required  by  the  operation  to  a  minimum,  and  at  the 
same  time  each  operation  Avhen  completed  is  technically  as  nearly  perfect  as 
it  can  be. 

Personal  efficiency.  During  the  past  few  years  very  extensive  studies 
have  been  made  for  increasing  the  efficiency  in  almost  every  industry  in  this 
country,  A  systematic  plan  has  been  employed,  known  as  the  Taylor  sys- 
tem, by  means  of  which  the  necessary  and  the  useless  or  harmful  motions 
have  been  determined  by  exhaustive  motion  studies.  Then  the  results  of 
these  studies  have  been  employed  for  the  purpose  of  eliminating  useless 
motions  and  systematizing  the  useful  motions  with  the  general  result  that 
the  efficiency  of  the  work  has  been  enormously  increased,  as  shown  by  the 
greatly  increased  production  with  the  expenditure  of  the  same  amount  of 
energy. 

Similar  studies  as  applied  to  surgical  operations  have  shown  that  in  gen- 
eral the  percentage  of  efficiency  is  exceedingly  low,  probably  because  no  one 
has  given  the  matter  any  attention  heretofore.  Of  course  it  must  be  plain 
to  every  one  that  now  the  subject  has  been  brought  to  our  attention,  we 
will  soon  eliminate  to  a  great  extent  these  useless  motions  and  thus  greatly 
increase  our  efficiencj^,  with  the  result  that  without  any  haste  the  time  of 
each  operation  will  be  greatly  reduced.  This  will  in  turn  reduce  the  amount 
of  anesthetic  given,  the  amount  of  unnecessary  trauma,  the  time  the  tissues 
are  exposed  to  the  possibility  of  infection,  and  the  time  during  which  blood 
may  be  lost  through  oozing  from  exposed  wound  surfaces. 

In  the  meantime,  to  accomplish  this  end  instruments  will  have  to  be 
standardized  precisely,  as  it  has  been  necessary  to  standardize  tools  in  factories, 
selecting  those  patterns  which  enable  the  artisan  to  increase  his  efficiency, 
at  the  same  time  reducing  the  number  and  variety  to  a  minimum. 

The  opportunity  young  surgeons  noAv  have  for  increasing  their  efficiency 
while  acting  as  hospital  assistants  will  undoubtedly  greatly  aid  in  developing 
this  departure. 


88  GENERAL  SURGICAL  CONSIDERATIONS 

It  may  be  repeated  that  in  almost  every  modern  mechanical  or  technical 
industry  an  attempt  is  being  made  to  standardize  the  implements  employed 
with  the  result  of  greatly  increasing  the  efficiency.  In  surgery  this  has  not 
been  done  systematically,  although  the  practice  of  the  progressive  surgeon  to 
visit  many  clinics  and  to  select  therefrom  not  the  most  unusual,  but  the  most 
practical  instruments  and  procedures  used  by  the  most  successful  surgeons 
has  resulted  in  the  general  adoption  of  many  good  aids  and  devices,  so  that 
there  has  resulted,  in  a  measure,  a  natural  standardization  of  the  instruments 
which  are  used  in  the  greatest  number  of  cases  by  man,y  surgeons. 

In  order  to  satisfy  a  request  which  has  frequently  been  made  we  herewith 
include  a  list  of  instruments  of  this  class  which  we  have  found  satisfactory 
after  long-continued  use. 

Kocher  hemostatic  forceps  and  Kelly  hemostatic  forceps.  These  instruments 
have  a  box  joint  and  are  for  this  reason  true  in  the  apposition  of  the  jaws  and 


"aWKaf  6  SWnVi  CNVvtWi^ 


can  be  used  to  compress  arteries  grasped  with  the  end  of  the  forceps,  or 
pedicles  or  broad  surfaces  may  be  grasped  between  the  long  serrated  jaws. 
These  instruments  can  be  used  in  two  sizes. 


Allis'  anastomosis  forceps.   This  instrument  is  extremely  useful  in  grasping 
and  holding  fine  edges,  as  in  suturing  intestines,  stomach,  gall-bladder,  etc. 


GENERAL  SURGICAL  CONSIDERATIONS 


89 


Stone's  tissue  forceps.     It  is  well  to  select  one  form  of  tissue  forceps  and 
then  adhere  to  its  use.    This  form  has  been  most  satisfactory  in  our  practice. 


Scissors.  Aside  from  the  usual  straight  and  curved  scissors  it  seems  worth 
while  to  direct  attention  to  Mayo's  dissecting  scissors  with  blunt  points  to  pre- 
vent injuring  nerves  and  other  delicate  structures,  and  the  very  convenient 
fiat-angle  scissors  of  Ferguson. 


rii  Mil  1 1  in  ■■ 


^^3 


Mayo  Robson's  gall  stone  scoop  is  useful  wherever  a  blunt  scoop  is  indicated. 


Shoemaker's  rib  shears  are  powerful  and  can  be  placed  around  the  rib 
without  danger  of  injuring  the  pleura. 


90 


GENERAL  SURGICAL  CONSIDERATIONS 


A  simple  soldering  iron  which  can  be  purchased  at  any  hardware  store  is 
often  useful.  It  can  be  heated  in  the  gas  tiame  of  a  Bunsen  burner  or  a  large 
alcohol  lamp,  or  by  placing  in  the  hot  coal  of  an  ordinary  stove  or  grate  fire. 


It  is  important  to  have  an  easily  adjustable  lamp  on  a  head-band.     This  is 
often  of  very  decided  assistance. 


Whitehead's  mouth  ga-g  keeps  the  mouth  open  uniformly  without  danger 
to  the  teeth. 


Gottstein's  adenoid  curette  is  a  useful  instrument. 


The  Moses  Gunn  tonsillotome  makes  it  possible  to  make  a  clean  tonsil- 
lectomy after  first  loosening  the  tonsil.  The  spearlike  fork  elevates  the  tonsil 
^0  that  it  can  be  cut  off  at  its  base. 


J 


GENERAL  SURGICAL  CONSIDERATIONS 


91 


La  Fort's  urethral  sounds  with  filiform,  being  conical  in  shape  are  exceed- 
ingly satisfactory  instruments. 


A  small-sized  Emmet's  trocar  is  useful  for  emptying  distended  gall-bladders, 
cysts,  abscesses  and  hydrothorax;  the  lateral  branch  of  the  canula  prevents 
soiling  of  surrounding  tissues. 


92 


'  GENERAL  SURGICAL  CONSIDERATIONS 


SHARP  &  SMITH 


Collins'  retractors  are  very  convenient.  They  are  not  heavy  enough  to 
permit  crushing  of  tissues  but  sufficiently  strong  to  retract  the  edges  of  large 
wounds. 


Thomas'  prostatic  spoon.  This  instrument  was  invented  for  the  purpose 
of  elevating  the  prostate  gland  in  suprapubic  prostatectomy  by  inserting  the 
spoon-like  end  into  the  rectum,  but  it  can  be  used  most  satisfactorily  in  many 
other  operations,  for  instance,  as  a  retractor  in  gall-bladder  and  common  duct 
operations  and  for  the  purpose  of  keeping  the  intestines  out  of  the  way  in 
closing  the  abdominal  incision. 


The  accompanying  cut  shows  a  nail-cleaner  which  does  not  injure  either  the 
nail  nor  the  soft  tissues,  but  thoroughly  cleanses  the  space  about  the  nail. 


The  self-retaining  catheter  with  the  mushroom-shaped  end  is  useful  not 
only  in  draining  the  female  bladder  but  also  the  gall-bladder  or  any  other 
cavity  for  which  a  self-retaining  drain  is  desired. 


Ferguson's  cutting-edge  prostate  forceps  is  an  excellent  instrument  for 
cutting  away  any  tissue  which  cannot  be  reached  conveniently  with  scalpel  or 
scissors.    The  curved  form  is  usually  to  be  preferred. 


GENERAL  SURGICAL  CONSIDERATIONS 


93 


Young's  prostatic  lobe  forceps  is  not  only  most  useful  in  grasping  the  pro- 
state but  in  many  other  operations/ it  has  a  distinct  field  of  value. 


Denhart's  mouth-gag'  is  powerful  and  reliable. 


Senn's  tongue  forceps  can  also  be  used  to  excellent  advantage  for  the  pur- 
pose of  holding  scalp  and  bone  flap  together  in  osteoplastic  resection  of  the 
skull. 


Linnartz's  anastomotic  clamp.  This  instrument  is  sufficiently  firm  to  hold 
stomach  and  intestine  in  position  without  danger  of  injuring  any  of  the 
structures. 


94 


GENERAL  SURGICAL  CONSIDERATIONS 


The  hemorrhoid  clamp  combines  all  of  the  good  qualities  of  all 
clamps,  together  with  great  convenience  because  of  the  lock  at  the  end 
handles. 


other 
of  the 


Henrotin's  vulsellum  forceps  are  strong  and  reliable. 


One  of  the  great  annoyances  in  the  use  of  cocaine  and  novocain  comes  from 
being  offered  unreliable  syringes.  By  having  a  set  of  Luer's  all-glass  syringes 
this  annoyance  is  eliminated. 


GENERAL  SURGICAL  CONSIDERATIONS 


95 


J.  F.  Percy's  improved  electric  cautery  outfit,  with  improved  rheostat. 


i 


i 


PART  II 

SURGERY  OF  THE  HEAD 


INJURIES  TO  THE  SCALP 

Infection  favored  by  location.  In  considering  scalp  injuries  it  is  important 
to  bear  in  mind  the  fact  that  the  conditions  in  this  location  are  especially- 
favorable  for  the  occurrence  of  infection,  and  that  it  is  especially  in  persons 
who  are  most  liable  to  scalp  injuries  that  the  conditions  are  most  favorable  for 
infection,  primarily  because  working  people,  and  notably  those  working  among 
horses  and  cattle  and  on  the  streets,  are  certain  to  have  unclean  scalps,  and, 
secondly,  the  dirt  with  which  they  come  m  contact  is  most  likely  to  contain 
pathogenic  micro-organisms,  of  which  the  pyogenous  staphylococci  and  strep- 
tococci are  most  numerous.  In  persons  working  among  horses  the  tetanus 
bacillus  is  also  frequently  present.  It  is  consequently  proper  at  this  point  to 
refer  to  the  matter  of  disinfection  of  the  scalp,  as  this  is  of  the  very  greatest 
importance,  even  though  there  may  be  no  fracture  of  the  skull.  The  scalp  is 
likely  to  contain  the  streptococci  of  erysipelas,  and  this  infection  may  extend 
through  the  skull  by  way  of  the  veins — giving  rise  to  a  septic  meningitis.  In 
our  experience  this  has  happened  in  a  number  of  cases  in  which  the  injury 
was  due  to  a  blow  with  a  blunt  object,  such  as  a  brick  or  a  piece  of  iron,  or 
anything  hard  or  heavy.  The  disinfection  in  these  cases  should  be  just  as 
thorough  as  though  an  operation  were  contemplated ;  and  it  is  well  afterward 
to  apply  a  moist,  antiseptic  dressing  of  some  kind  and  cover  with  some  imper- 
meable material,  such  as  gutta  percha,  in  order  to  complete  the  disinfection. 
The  sooner  this  is  accomplished  after  the  time  of  the  injury  the  better.  It  is  • 
unfortunate  if  it  be  postponed  until  the  tissues  have  become  edematous  as  a 
result  of  infection. 

In  these  cases  the  amount  of  hemorrhage  has  usually  been  so  considerable 
that  the  hair  is  thoroughly  saturated  with  blood. 

Antiseptic  measures.  If  the  wound  is  fairly  clean-cut  and  not  very  large 
it  usually  suffices  to  wash  the  scalp  thoroughly  with  soap  and  hot  water,  then 
to  shave  away  the  hair  for  one  or  two  cm.  beyond  the  edge  of  the  wound  in 
all  directions  and  then  to  wash  the  surface  with  strong  alcohol  and  with  one 
to  one-thousand  corrosive  sublimate  in  hot  water;  then  again  with  strong 
alcohol  and  finally  to  mop  the  wound  and  the  surrounding  scalp  with  strong 
compound  tincture  of  iodine. 

If  the  wound  is  very  small  and  if  one  is  certain  that  there  is  no  fracture 
of  the  skull  it  is  often  not  necessary  to  shave  away  any  of  the  hair  if  the  scalp 
is  thoroughly  treated  according  to  the  method  just  described. 

On  the  other  hand,  if  the  scalp  has  been  badly  crushed  and  if  the  wound 
is  extensive,  and  especially  if  there  is  a  fracture  of  the  skull,  it  is  often  best 
to  shave  the  entire  head  so  that  in  the  manipulations  which  will  be  required 
in  treating  the  conditions  found,  there  may  be  no  danger  of  carrying  infectious 
material  from  the  remaining  hair  to  the  wound  and  to  the  meninges. 

Application  of  tincture  of  iodine.     Recently  disinfection  without  prelim- 

7 

97 


98  SURGERY  OF  THE  HEAD 

inary  scrubbing  by  saturating  the  dry  surface  with  strong  tincture  of  iodine, 
or  10  per  cent,  of  iodine  dissolved  in  benzine  or  in  chloroform,  has  been  advo- 
cated. In  cases  in  w^hich  the  wound  has  been  kept  dry,  the  results  seem  to  be 
better  by  simply  using  the  iodine  than  by  washing  with  soap  and  water  and 
antiseptics. 

Clean-cut  scalp  wounds.  When  the  wound  is  clean-cut  and  there  is  no 
undermining  of  the  scalp,  it  is  well  simply  to  apply  tincture  of  iodine  to  the 
wound  and  to  the  surrounding  scalp,  and  place  just  a  sufficient  number  of 
sutures  to  secure  coaptation,  but  no  more,  in  order  to  permit  the  serum  to 
escape  between  the  sutures.  This  will  insure  rapid  healing,  if  there  is  a 
slight  amount  of  infection,  because  the  blood  supply  is  very  abundant  and  the 
serum  escaping  between  the  sutures  will  eliminate  safely  a  considerable 
amount  of  septic  material. 

When  the  tissues  are  undermined.  If  the  edges  of  the  wound  are  under- 
mined the  wound  should  be  enlarged  to  a  point  just  beyond  the  undermined 
portion,  tincture  of  iodine  applied  and  then  sutured,  with  a  little  space  left 
open  at  each  end  for  drainage.  If  the  undermining  is  extensive  it  is  well  to 
make  one  or  more  small  incisions  at  the  base  of  each  flap  caused  by  the  under- 
mining, and  in  bad  cases  to  draw  a  small  drainage  tube,  or  strands  of  silk- 
worm gut,  or  folded  gutta  percha  tissue,  through  these  openings  to  facilitate 
drainage.  If  tincture  of  iodine  alone  has  been  used  for  disinfecting  the  wound 
it  should  be  covered  with  a  plain  dry  sterile  gauze  dressing.  On  the  other 
hand,  if  the  wound  has  been  Avashed  with  soap  and  water  and  the  usual  anti- 
septics, it  is  desirable  then  to  cover  it  with  a  hot  moist  dressing  composed  of 
gauze  saturated  with  a  mixture  of  three  parts  of  saturated  boric  acid  solution 
and  one  part  of  alcohol.  Some  impermeable  substance,  like  gutta  percha  tissue 
or  oiled  silk,  is  placed  over  this  and  cotton  and  a  bandage  over  all. 

Infected  scalp  wounds.  It  frequently  happens  that  scalp  wounds  are 
sutured  hurriedly,  without  sufficient  cleansing,  directly,  or  some  time  after 
their  occurrence,  or  that  they  are  not  cared  for  at  all  for  some  hours,  or  even 
days,  after  their  infliction,  and  that  when  they  flnally  come  under  the  atten- 
tion of  a  surgeon  infection  has  taken  place,  which  may  be  of  any  degree  of 
severit.y,  from  the  slightest  infection  to  a  degree  so  severe  that  the  patient 
may  have  a  temperature  of  105°,  or  even  be  unconscious. 

In  these  severe  cases  it  is  wise  to  invariably  remove  all  of  the  sutures  and 
to  open  up  the  wound  widely.  Upon  doing  this  we  have  found  all  kinds  of 
objects,  like  hair,  straw,  splinters  of  wood,  sand  and  dirt  and  many  other 
things  sewed  up  in  such  scalp  wounds.  In  these  cases  the  wound  should  be 
enlarged  to  the  extent  of  the  undermining  and  a  number  of  small  incisions 
made  at  the  base  of  each  flap.  The  space  underneath  the  flaps  should  then  be 
loosely  packed  with  moist  gauze  and  the  entire  scalp  covered  with  the  hot, 
moist,  antiseptic  dressing  previously  described.  This  should  be  renewed  daily 
until  the  sepsis  has  entirely  subsided  and  then  the  edges  of  the  wound  should 
be  sutured  loosely  and  dressed  as  a  clean  scalp  wound. 

Immunizing  tetanus  antitoxin.  If  the  wound  has  been  soiled  with  street 
dust  or  with  garden  earth,  or  if  the  patient  has  recently  come  in  contact  with 
horses,  from  1,000  to  3,000  units  of  tetanus  antitoxin  should  be  injected  sub- 
cutaneousl5%  and  repeated  twice  at  intervals  of  twenty-four  hours.  If  the 
scalp  wound  is  in  the  vicinity  of  the  external  auditory  meatus  it  is  advisable 
to  place  a  few  drops  of  strong  compound  tincture  of  iodine  in  the  meatus,  so 
that  all  parts  of  its  surface  will  be  covered  with  this  remedy,  and  after  half 
an  hour  the  ear  should  be  filled  with  a  ten  per  cent,  solution  of  carbolic  acid  in 
glycerine.  This  application  of  carbolic  acid  and  glycerine  should  be  repeated 
once  or  twice  dailv  until  it  is  certain  that  the  wound  will  not  have  an  erysip- 


SURGERY  OF  THE  HEAD  99 

elatoTis  complication.  In  case  this  should,  however,  occur  the  treatment  should 
be  continued  in  order  to  prevent  an  infection  of  the  raeninges  through  this 
channel. 

TUMORS  OF  THE  SCALP 

Sebaceous  cysts.  The  most  common  tumors  in  this  region  are  sebaceous 
cysts,  which  may  vary  in  size  from  that  of  a  bird-shot  to  that  of  a  fist,  although 
they  usually  become  infected  before  attaining  extreme  size  and  they  then 
necrose  at  some  point  and  their  contents  become  spontaneously  evacuated 
through  the  opening  thus  formed.  They  may  also  be  injured  by  the  use  of 
comb  or  hatpin  and  a  superficial  ulcer  thus  may  occur  which  usually  induces 
the  patient  to  give  the  condition  surgical  attention. 

There  is  no  pain  in  these  cysts  unless  they  are  inflamed,  but  they  are  the 
cause  of  marked  deformity  and  much  inconvenience  in  dressing  the  hair. 

Modem  treatment  and  recurrence.  In  pre-antiseptic  days  there  was  much 
prejudice  against  surgical  treatment  of  this  condition  because  of  frequent 
recurrence,  and  the  operation  was  often  followed  by  an  erysipelas  which 
sometimes  resulted  in  the  death  of  the  patient.  The  first  objection  has  now 
been  eliminated-  owing  to  the  certainty  with  which  it  is  possible  to  remove  the 
entire  cyst  wall.  It  is,  however,  to  be  born  in  mind  that  every  sebaceous 
gland  in  the  scalp  is  capable  of  forming  a  sebaceous  cyst,  and  consequently  the 
removal  of  the  existing  cysts  will  not  pre^'ent  the  formation  of  further  similar 
cysts  from  any  of  the  remaining  sebaceous  glands  in  the  part. 

It  would  consequently  not  be  wise  to  give  the  patient  the  impression  that 
by  having  the  existing  cysts  removed  he  or  she  would  in  the  future  be  free 
from  this  condition.  Indeed,  it  has  been  found  that  persons  who  have  once 
had  sebaceous  cysts  of  the  scalp  are  especially  liable  to  the  formation  of  sim- 
ilar growths  from  other  sebaceous  glands  in  the  same  region.  It  is  also  well  to 
examine  carefully  all  of  the  portions  of  the  scalp  before  the  operation,  in  order 
to  discover  any  small  cysts  which  may  be  just  appearing. 

Early  in  the  antiseptic  era  it  was  customary  to  shave  the  entire  scalp  before 
removing  even  a  single  sebaceous  cyst,  in  order  to  secure  an  absolutely  per- 
fect asepsis.  This  is  no  longer  necessary,  as  it  has  been  found  that  if  the  plan 
of  disinfecting  the  scalp  that  has  just  been  described  is  carried  out  the  wound 
resulting  from  the  operation  will  regularly  heal  by  first  intention,  even  if  no 
part  of  the  hair  has  been  shaved. 

It  is  claimed  that  by  simply  saturating  the  dry  scalp  thoroughly  and 
repeatedly  with  compound  tincture  of  iodine  for  a  period  of  ten  minutes,  and 
permitting  this  to  become  dry,  that  the  operation  can  be  performed  safely 
without  any  further  attempts  at  disinfection.  In  place  of  the  compound 
tincture  of  iodine  a  ten  per  cent,  solution  of  iodine  in  benzine  or  in  chlorofrm 
may  be  employed. 

Our  own  results  have  been  so  absolutely  satisfactory  by  followinsr  the 
method  described  above  that  we  have  not  undertaken  to  test  these  iodine 
methods,  which  are,  however,  vouched  for  by  perfectly  reliable  authorities 
with  much  experience  and  good  surgical  judgment. 

Technique  of  removal.  The  cysts  having  been  definitely  located,  counted 
and  marked  by  the  application  of  a  spot  of  tincture  of  iodine  directly  over  the 
mass,  the  hair  is  seT)arated  and  a  sharp-pointed  scalpel  is  thrust  directly 
through  the  scalp  and  the  underlying  cyst,  splitting  the  latter  and  its  contents 
in  halves.  The  cyst  wall  is  much  more  adherent  to  the  surrounding  tissues  at 
its  most  superficial  point  than  elsewhere  on  its  surface,  hence  it  is  wise  to 
grasp  the  deepest  portion  of  the  cyst  wall  with  hemostatic  or  dissecting  for- 
ceps and  to  enucleate  it  from  within  outwards.    In  a  fraction  of  a  minute  a 


100  SURGERY  OF  THE  HEAD 

cyst  can  be  removed  in  this  manner  and  unless  too  large  a  number  of  cysts  are 
present  the  work  can  be  done  without  general  or  local  anesthetics.  If  there 
are  several  of  these  cysts  present  it  is  well  to  administer  morphin  hypoder- 
mically  half  an  hour  before  the  operation  in  order  to  blunt  the  sensibility  of 
the  patient  to  some  extent. 

The  wound  must  be  carefully  examined  to  determine  that  no  part  of  the 
cyst  wall  has  been  left  behind.  If  these  steps  are  carefully  carried  out  it  is  but 
seldom  that  any  portion  of  the  cyst  wall  remains. 

This  method  is  much  more  satisfactory  than  the  removal  of  these  cysts  by, 
dissection,  not  only  because  of  its  ease  and  rapiditj^  but  also  because  of  thej 
fact  that  recurrence  follows  much  more  rarely,  if  at  all,  on  account  of  leaving] 
portions  of  the  cyst  wall.  From  one  to  three  fine  catgut  sutures  should  be 
introduced  and  a  gauze  and  cotton  dressing  applied,  which  may  be  removed] 
in  one  week. 

Lipomati.  Fatty  tumors  are  rare  in  the  scalp  in  comparison  with  seba- 
ceous cysts.  They  resemble  the  latter  somewhat,  but  are  deeper-seated  and! 
less  spherical  in  shape,  presenting  a  more  flat  surface.  The  treatment  is 
excision  under  local  anesthesia.  The  removal  can  be  accomplished  quickly 
and  easily  by  making  an  incision  down  through  the  growth,  splitting  in 
halves,  then  peeling  each  half  out  separately,  the  same  as  in  removal  of  a! 
sebaceous  cyst. 

Warts  and  moles.  Warts  and  moles  on  the  scalp  are  simple  cutaneous 
hypertrophies  but  are  apt  to  be  quite  annoying  from  the  frequent  traumatism 
received  while  combing  the  hair.  This  irritation  may  be  the  cause  of  thej 
growth  occasionally  taking  on  a  malignant  nature.  These  growths  should  be! 
excised.     This  can  easily  be  done  under  local  anesthesia. 

Nevus.  Two  varieties  are  met  with  in  the  scalp  depending  upon  the  size] 
of  the  blood  vessels  making, up  the  tumor.  When  the  growth  is  composed  of] 
fine  capillaries  it  consists  of  a  discoloration  of  the  scalp  known  as  a  "port -wine! 
stain,"  with  little  or  no  tendency  to  spread,  usually  causing  no  trouble  other! 
than  the  annoyance  the  patient  suflfers  from  discoloration.  If  it  is  located 
entirely  above  the  hair  line  no  treatment  is  indicated.  If  it  extends  onto  the' 
forehead  oi*  neck  its  removal  is  best  accomplished  by  freezing  the  surface  with 
carbon-dioxide  snow. 

This  snow  may  easily  be  obtained  from  an  ordinary  carbon-dioxide  gas 
tank  such  as  used  in  the  laboratory  or  soda  fountain,  etc.  The  snow  is  col- 
lected by  placing  a  piece  of  chamois  leather  in  the  shape  of  a  small  bag  about 
the  neck  of  the  gas  tank,  allowing  the  gas  to  escape  rather  rapidly  into  the 
bag.  Snow  is  immediately  formed.  The  snow  is  cut  into  convenient  sized 
blocks,  and  then  is  held  against  the  surface  of  the  nevus  for  a  period  of  twenty 
to  thirty  seconds.  This  causes  a  destruction  of  the  superficial  capillaries  but 
does  not  freeze  deep  enough  to  cause  a  sloughing  of  the  skin  with  scarring. 
Blebs  usually  occur  on  the  skin  following  the  freezing,  and  as  these  heal  the 
skin  loses  its  wine  color.  Occasionally  several  applications  of  the  snow  are 
necessary  before  the  desired  result  is  accomplished. 

When  the  capillary  vessels  are  large  they  form  a  slightly  elevated,  irregular 
mass  on  the  skin,  which  has  a  tendency  to  spread  rapidly,  its  walls  becoming 
thinner  until  ulceration  occurs,  resulting  in  severe  hemorrhage.  These  groAvths 
should  always  be  removed  as  soon  as  they  are  discovered,  which  is  usually 
when  they  are  quite  small.  At  this  time  they  can  be  excised  and  the  wound 
sutured  without  dif^culty.  Later  after  they  have  increased  in  size  it  is  usually 
necessary  to  cover  the  area  with  skin-grafts  after  the  tumor  has  been  removed. 
These  tumors  have  a  tendency  to  recur  unless  every  portion  of  the  involved 
blood  vessels  has  been  removed. 


SURGERY  OF  THE  HEAD  101 

Sarcoma  and  carcinoma.  Sarcoma  and  carcinoma  of  the  scalp  should  be 
treated  by  wide  excision,  together  with  periosteum  covering  the  skull.  It  is 
well  to  apply  the  actual  cautery  to  the  surface  of  the  bone  after  the  tumor  has 
been  removed  and  to  secure  deep  cauterization  of  the  bone  in  this  way.  The 
cauterized  bone  will  be  exfoliated  after  several  weeks  and  the  surface  may  be 
covered  with  Thiersch  skin-g-rafts,  unless  the  tumor  is  located  at  a  point  at 
which  this  would  leave  an  especially  unsightly  deformity,  in  which  event  the 
scalp  covered  with  hair  from  some  other  part  of  the  head  may  be  mobilized  in 
the  form  of  a  flap  of  proper  size  and  this  may  be  slid  over  the  defect  and 
sutured  in  place.  The  new  defect  which  has  been  formed  in  this  manner  should 
be  covered  with  Thiersch  grafts  at  once. 

TUBERCULOSIS  OF  THE  SCALP 

Tuberculosis  of  the  scalp  is  not  a  common  condition.  When  it  does  occur 
it  should  be  treated  by  the  method  just  described  for  the  relief  of  malignant 
growths,  unless  the  area  involved  is  small,  in  which  event  it  is  well  to  destroy 
the  infected  tissue  with  the  actual  cautery  down  to  the  skull,  including  the 
surrounding  tissue  for  a  distance  of  one  cm.  When  the  eschar  has  separated, 
the  surface  should  be  covered  by  a  Thiersch  skin-graft. 

NON-TRAUMATIC  INFECTION  OF  THE  SCALP 

Non-traumatic  infections  of  the  scalp  should  be  treated  like  the  same  condi- 
tions involving  other  parts  of  the  skin,  but  it  is  important  to  remember  the 
fact  that  apparently  non-traumatic  infections  of  this  region  are  usually  due 
to  traumatism  caused  by  the  presence  of  parasites,  or  to  scratching  to  relieve 
itching  of  the  scalp  which  is  not  kept  clean.  We  have  seen  more  of  this  since 
the  introduction  of  the  fantastic  fashion  of  hair-dressing  in  vogue  at  the 
present  time. 

In  the  former  ease  it  is  important  as  an  initial  step  to  destroy  the  parasites 
and  to  place  the  hair  and  the  scalp  in  an  aseptic  condition,  and  to  prevent 
reinfection  from  the  material  used  in  dressing  the  hair.  In  the  second  place, 
it  must  be  borne  in  mind  that  it  is  much  more  difficult  to  use  moist,  antiseptic 
dressings  effectively  on  hair-covered  skin  surfaces  unless  especial  attention  is 
paid  to  this  condition,  as  the  hair  is  likely  to  become  matted  together  and  to 
prevent  the  antiseptic  fluid  from  touching  the  underlying  skin. 

It  is  but  rarely  necessary  to  remove  the  hair,  however,  if  the  dressing  of 
these  cases  is  carried  out  carefully  and  intelligently,  but  if  left  to  assistants, 
without  especial  instruction,  they  usually  progress  badly. 

In  all  other  respects  the  treatment  must  be  the  same  as  for  infection  of 
other  portions  of  the  skin. 

INJURIES  OF  THE  SKULL 

Diagnosis,  Although  injuries  to  the  skull  are  more  commonly  associated 
with  wounds  of  the  scalp,  it  is  important  always  to  remember  that  the  absence 
of  an  external  wound  does  not  necessarily  mean  an  absence  of  skull  injury, 
and  it  is  just  in  these  cases  that  a  diagnosis  is  often  difficult  and  sometimes 
impossible.  If  a  definite  depression  of  the  bone  can  be  felt  the  diagnosis  is 
easily  made,  but  this  is  sometimes  simulated  by  an  abrupt  depression  due  to 
the  fact  that  the  subcutaneous  tissue  has  been  crushed  by  a  heavy,  sharp- 
edged  object,  which  has  left  a  portion  of  the  subcutaneous  tissue  entirely 
untouched,  while  the  tissue  just  beyond  has  been  so  thoroughly  crushed  that 
it  feels  like  a  depression,  and  the  sharp  edge  of  the  tissue  beyond  feels  like 
the  edge  of  the  fractured  bone. 


102  SURGERY  OF  THE  HEAD 

In  case  of  doubt  it  is  well  to  treat  the  general  condition  of  the  patient. 
Apply  cold,  antiseptic  dressings  to  the  scalp  and  watch  the  patient  carefully 
for  some  focal  symptoms. 

Fracture  of  the  skull  may  cause  no  immediate  symptoms  aside  from  the 
shock  and  temporary  unconsciousness  due  to  the  accompanying  concussion  of 
the  brain.  The  injury  may  consist  of  a  single  fissure  with  or  without  laceration 
of  periosteum  or  dura,  or  both,  or  it  may  be  accompanied  by  more  or  less  severe 
depression.  The  bone  may  be  driven  into  the  substance  of  the  brain,  or  the 
latter  may  be  quite  uninjured  because  of  its  elasticity  and  the  character  of 
the  blow. 

Of  the  injuries  to  the  blood  vessels  a  laceration  of  the  meningeal  artery  at 
some  point  is  most  common  and  this  is  by  far  the  most  treacherous  condition 
because  of  the  ease  with  which  it  may  be  overlooked  unless  the  possibility 
of  its  occurrence  is  kept  very  prominently  in  one's  mind,  even  in  connection 
with  head  injuries  which  at  first  seem  so  slight  as  to  be  scarcely  worthy  of 
serious  attention. 

The  authors  have  recently  encountered  three  cases  of  rupture  of  the  middle 
meningeal  artery,  all  of  which  were  caused  by  being  struck  on  the  head  by  a 
base-ball,  and  none  presenting  any  serious  immediate  symptoms,  but  each  one 
giving  an  entirely  different  later  history. 

First  case  a  boy  of  fifteen  while  playing  base-ball  was  struck  in  the  right  temporal  region 
by  a  ball.  Patient  was  not  rendered  unconscious  at  all,  was  able  to  get  up  from  the  ground 
unaided,  and  walked  home  a  distance  of  one  mile.  Two  hours  later  while  eating  supper  he  sud- 
denly developed  a  left  hemiplegia  which  affected  both  arm  and  leg.  Did  not  lose  consciousness. 
Operation  same  evening  revealed  rupture  of  the  middle  meningeal  artery. 

Case  2.  A  young  man  twenty-two  years  of  age  struck  in  left  temporal  region  with  base- 
ball, fell  but  was  not  unconscious.  Got  up  and  walked  home,  but  felt  rather  dazed  for  twenty- 
four  hours.  At  end  of  forty-eight  hours  began  to  have  convulsions  occurring  at  intervals  of 
two  hours.  Between  eon-vnlsions  was  conscious  but  had  difficulty  in  talking.  Could  answer 
questions  yes  or  no,  but  did  not  have  the  power  to  form  sentences.  No  other  focal  symptoms. 
Operation  at  end  of  third  day  revealed  ruptured  middle  meningeal  artery. 

Case  3.  Young  man,  age  twenty-one,  struck  in  left  temporal  region  by  base-ball.  Fell  to 
ground  and  was  unconscious  about  five  minutes.  After  this  walked  home  without  any  difficulty, 
apparently  as  well  as  usual.  Patient  took  up  his  farm  work  as  usual,  driving  a  harvester 
machine.  He  continued  this  work  for  four  days,  feeling  well  except  that  there  was  an  interval  of 
five  or  ten  minutes  each  day,  during  which  time  he  felt  that  he  was  "out  of  his  head."  On 
the  evening  of  the  fourth  day,  while  milking  a  cow,  he  suddenly  fell  over  unconscious  and 
remained  so  for  twelve  hours.  Two  days  later  examination  revealed  no  symptoms  except  patient 
was  very  slow  in  answering  questions,  stating  that  it  was  difficult  to  find  words  to  express  him- 
self.    Operation  revealed  rupture  of  the  middle  meningeal  artery. 

These  cases  very  commonly  have  the  following  history :  A  patient  receives 
a  slight  injury  from  which  he  recovers  in  a  very  short  time,  usually  Avithin  a 
few  minutes.  He  is  able  to  go  to  his  home,  but  later  on  becomes  unconscious, 
his  pulse  becomes  slow,  and  unless  relief  is  secured  within  a  very  short  time 
he  succumbs  to  the  effects  of  intra-cranial  pressure.  This  history  is  usually  so 
clear  and  the  symptoms  so  pronounced  that  there  is  little  difficulty  in  making 
the  proper  diagnosis  unless  the  surgeon  is  called  too  late,  or  if  the  patient's 
primary  injury  has  been  overlooked  on  account  of  the  apparent  slightness  of 
its  character. 

Choked  disc  on  the  same  side  is  usually  present  as  soon  as  the  symptoms  of 
pressure  appear.  One  should  always  make  a  careful  ophthalmoscopic  exam- 
ination in  these  cases. 

The  treatment  must  be  applied  at  once,  for  if  it  is  neglected  the  patient's 
condition  will  soon  become  hopeless. 

In  injuries  of  the  skull  when  it  looks  like  the  patient  is  going  into  a  state 
of  coma  on  account  of  rupture  of  the  middle  meningeal  artery,  Murphy  sug- 
gested an  immediate  ligation  of  the  external  eartoid  artery  under  local  anes- 


SURGERY  OF  THE  HEAD 


103 


thesia.  This  will  stop  the  hemorrhage  at  once,  as  the  middle  meningeal  artery 
is  a  branch  of  the  internal  maxillary  artery,  which  is  a  subdivision'  of  the 
external  carotid.  Now  that  the  hemorrhage  has  been  controlled,  relieving  the 
patient  of  any  immediate  danger,  the  surgeon  can  take  his  time  to  do  the 
trephining. 

LIGATION  OF  THE  MIDDLE  MENINGEAL  ARTERY 

The  danger  of  infection  of  the  meninges  is  greatly  reduced  by  thoroughly 
shaving  the  entire  scalp  before  the  commencement  of  the  operation.  If  only 
a  small  portion  of  the  surface  is  shaved  it  is  likely  that  during  some  part  of 
the  operation  some  one  will  carry  infectious  material  from  the  remaining  por- 


DeVilbiss  Forceps  and  Proper  Trephine. 


tion  of  the  scalp  to  the  wound  and  thus  cause  an  infection,  which  in  these  cases 
is  always  serious.  If  the  entire  scalp  has  been  carefully  shaved  the  further 
disinfection  is  no  more  difficult  than  disinfection  of  the  skin  in  any  other 
portion  of  the  body. 

If  the  point  of  injury  can  be  distinctly  located  in  the  course  of  one  of  the 
principal  branches  of  the  middle  meningeal  artery,  the  point  of  operation  can 
be  determined  in  this  manner.  If  this  cannot  be  done  it  will  become  necessary 
to  expose  first  one  and  then  the  other  of  the  principal  branches  of  this  vessel, 
provided  the  first  attempt  fails ;  or  it  may  be  better  to  expose  both  branches 
at  once  by  making  an  osteoplastic  resection  of  a  portion  of  the  skull,  covering 
both  the  anterior  and  the  posterior  branches  of  the  middle  meningeal  artery. 
The  following  guide  will  suffice  to  locate  these  branches : 

The  anterior  branch  crosses-  a  point  one  and  one-fourth  inches  backward 
and  upward  from  the  external  angular  process  of  the  frontal  bone.  The 
posterior  branch  crosses  a  point  at  which  this  line  divides  a  line  drawn  verti- 
cally from  the  anterior  edge  of  the  mastoid  process.  An  opening  can  be  made 
at  these  points  by  means  of  a  trephine  one-half  inch  in  diameter ;  the  instrument 
should,  however,  be  conical  in  shape  so  that  as  soon  as  the  inner  table  of  the 
skull  has  been  perforated  by  it  the  instrument  is  stopped  automatically  from 
penetrating  deeper  and  causing  an  injury  to  the  dura.  It  is  usually  best  to 
make  an  oval  skin-flap  covering  the  area  traversed  by  both  the  posterior  and 


104  SURGERY  OF  THE  HEAD 

the  anterior  branches  of  the  middle  meningeal  artery,  so  that  if  the  injury 
is  not  found  in  the  anterior  branch,  which  is  most  commonly  the  seat  of  trouble, 
an  elliptical-shaped  flap  of  the  parietal  bone  may  be  cut  loose  by  means  of 
DeVilbiss  forceps.  In  this  way  much  time  can  be  saved  and  the  surface  can 
be  so  thoroughly  exposed  that  no  error  is  possible. 

In  making  the  resection  of  the  skull  the  size  and  form  of  the  flap  may  be 
regulated  by  directing  the  instrument.  A  flap  sufficiently  large  to  cover  the 
space  occupied  by  the  posterior  and  anterior  branches  of  the  middle  meningeal 
artery  can  be  cut  with  the  DeVilbiss  forceps  in  a  very  short  time,  usually  less 
than  ten  minutes  being  required  for  this  purpose.  It  is,  however,  necessary 
to  bear  in  mind  the  technique  required  in  the  use  of  these  forceps.  The  cut- 
ting portion  of  the  forceps  should  be  introduced  through  the  originally  pro- 
vided opening,  and  then  it  should  be  slid  along  the  cut  which  has  already  been 
made  until  the  end  is  engaged  under  the  portion  of  the  skull  to  be  severed. 
Unless  this  precaution  is  taken  the  work  will  progress  very  slowly.  The  small 
bridge  at  the  base  of  the  bone-flap  is  weakened  by  the  application  of  a  few 
strokes  of  the  chisel  and  then  it  is  fractured  by  inserting  a  strong  chisel 
opposite  this  point  and  elevating  the  flap.  The  bleeding  vessel  is  now  exposed 
and  ligated  by  passing  about  it  a  fine,  catgut  ligature  threaded  in  a  needle, 
the  clot  is  sponged  away,  the  bone  flap  is  replaced,  and  the  overlying  skin  is 
sutured.  If  there  is  still  some  oozing  after  the  injured  portion  of  the  meningeal 
artery  has  been  ligated  it  is  wise  to  place  a  small  capillary  drain  underneath 
the  flap  to  prevent  re-accumulation  of  blood. 

CHRONIC  SUBDURAL  HEMORRHAGE 

Occasionally  the  hemorrhage  from  some  very  small  ruptured  branch  of  the 
meningeal  artery  is  so  slow  that  no  immediate  symptoms  are  discovered  for 
days  or  weeks,  or,  as  in  one  of  our  own  cases,  for  three  months. 

The  first  symptoms  may  consist  of  only  slight  headaches,  with  a  feeling  of 
pressure  in  the  region  where  the  blood  is  accumulating.  Later  the  pain 
becomes  more  severe,  but  frequently  the  injury  to  the  head  has  been  for- 
gotten by  the  patient  and  his  friends,  so  that  the  surgeon  does  not  receive  any 
information  regarding  this  most  important  element  of  the  history.  Then 
pressure  symptoms  occur  in  the  form  of  paralysis,  and  if  the  pressure  is  over 
the  area  of  the  speech  center  there  may  be  at  first  some  slight  difficulty  in 
articulation,  which  becomes  more  and  more  marked  until  complete  aphasia 
occurs.  Later  the  irritation  caused  by  the  pressure  may  result  in  mania. 
Aside  from  these  symptoms  the  typical  evidences  of  increased  intra-cranial 
pressure  maj^  be  noticed.  This  usually  gives  rise  to  a  diagnosis  of  intra-cranial 
tumor  unless  the  condition  is  attributed  to  the  original  injury. 

Treatment.  The  method  of  operating  is  the  same  as  for  ligation  of  the 
middle  meningeal  artery  as  regards  the  formation  of  skin  and  bone  flaps. 
When  the  dura  has  been  exposed  it  will  be  found  to  bulge  and  no  pulsation 
can  be  detected. 

An  incision  of  the  dura  will  evacuate  either  clotted  blood  or  serum,  or 
both.  In  cases  in  which  the  injurj^  has  occurred  a  considerable  time  before 
the  operation  the  cavity  is  likely  to  contain  only  serum,  which  is  usually 
colored  with  blood  pigment.  This  accumulation  may  vary  in  size  from  a  few 
cc.  to  500  cc.  or  more. 

It  is  surprising  how  quickly  the  symptoms  disappear,  even  in  cases  that 
have  suffered  from  cerebral  compression  for  a  considerable  period,  provided 
the  increase  in  pressure  was  very  gradual. 

The  wound  in  the  dura  should  be  closed  with  fine,  catgut  sutures.  Some 
silkworm  gut  strands  or  some  folded  gutta  percha  tissue  should  be  used  for 


I 


SUEGERY  OF  THE  HEAD  105 

drainage  from  one  angle  of  the  wound  and  a  large  external  dressing  should  be 
applied.  In  one  of  our  cases  there  was  a  slight  re-accumulation  probably  from 
secretion  from  the  walls  of  the  space  in  which  the  original  accumulation  had 
taken  place.  Simply  reopening  one  angle  of  the  wound  very  slightlj^  permitted 
this  tiuid  to  escape  and  then  the  recovery  progressed  uninterruptedly  and  the 
patient  remained  permanently  well. 

Important  to  recognize  the  indications.  It  is  really  very  important  to  bear 
this  condition  in  mind  in  dealing  with  patients  suffering  from  headaches  and 
other  pressure  symptoms,  because  most  of  the  reported  cases  suffered  for  a 
long  time  before  a  diagnosis  was  made.  The  condition  is  undoubtedly  never 
recognized  in  many  cases.  If  the  fluid  accumulates  more  rapidly  these  patients 
die  from  cerebral  compression. 

SIMPLE  DEPRESSED  FRACTURES  OF  THE  SKULL 

Do  not  delay  elevating.  In  the  treatment  of  acute  injuries  of  the  skull, 
it  is  important  to  remember  that  depressed  fractures,  although  frequently  not 
accompanied  by  serious  symptoms  at  the  time  of  the  injury,  are  likely  to 
result  in  exceedingly  serious  late  conditions,  unless  the  difficulty  is  rqlieved 
quickly  after  the  injury.  The  irritation  resulting  from  a  depressed  fracture 
frequently  gives  rise  to  epilepsy  at  some  time  after  the  occurrence  of  the 
injury.  In  order  to  prevent  this,  it  is  important  in  every  case  in  which  there 
is  a  depressed  fracture  to  elevate  this  at  once,  which  can  be  accomplished  by 
exposing  the  seat  of  the  fracture  by  an  incision  through  the  scalp,  the  latter 
having  been  shaved  as  indicated  in  connection  with  previous  operations  on  the 
part.  If  the  fracture  is  comminuted  a  small  portion  of  the  bone  can  usually  be 
removed  by  the  introduction  of  the  sharp  edge  of  a  chisel,  and  with  the  use  of 
this  instrument,  together  with  the  sequestrum  forceps,  it  is  usually  possible 
to  adjust  the  portions  of  the  depressed  fracture  very  accurately.  If  this  can- 
not be  done  it  is  safer  to  sacrifice  some  portions  of  the  skull  than  to  leave  any 
depressed  part  to  irritate  the  meninges. 

If  an  injury  is  found  in  the  dura  this  should  be  sutured  with  fine  catgut. 
After  the  skull  has  been  carefully  adjusted  the  scalp  is  sutured  over  this  with 
or  without  capillary  drainage,  according  to  the  amount  of  oozing  that  remains. 
Care  should  be  taken  to  sacrifice  as  little  as  possible  of  the  skull,  and  in  simple 
fractures  fragments  may  be  replaced  with  safety,  although  they  may  be 
entirely  separated  from  the  dura  and  the  periosteum.  In  compound  fractures 
the  same  plan  of  treatment  must  be  pursued,  with  the  addition  of  very  careful 
disinfection,  the  removal  of  all  fragments  of  the  skull  which  may  have  become 
infected  in  the  least  and  the  use  of  drainage  in  all  of  these  cases. 

Choice  of  bone  chisel.  In  all  chiseling  operations  upon  the  skull  and  eleva- 
tion of  fragments,  the  ordinary  carpenter's  chisel  and  a  mallet,  such  as  the 
ones  used  by  wood  carvers,  are  of  the  greatest  convenience.  Most  bone  chisels 
obtained  in  instrument  stores  are  practically  useless  for  this  purpose,  because 
they  are  either  clumsy  or  difficult  to  handle,  while  the  carpenter's  chisel  can 
be  used  with  ease  by  any  one  who  has  the  least  manual  dexterity.  A  convenient 
amount  of  bone  may  be  cut  away  in  a  few  moments  with  this  instrument,  and 
.the  form  of  the  incision  in  the  bone  can  be  easily  controlled.  The  chisels  are 
so  sharp  that  their  use  does  not  give  rise  to  any  severe  concussion.  This  is 
especially  true  if  the  edge  of  the  chisel  is  held  nearly  parallel  with  the  surface 
of  the  bone.  A  number  of  chisels  should  be  at  hand,  so  that  if  any  defect 
occurs  in  one  it  may  be  laid  aside  and  another  substituted  at  once. 

COMPOUND  FRACTURES  OF  THE  SKULL 

Most  compound  fractures  of  the  skull  are  associated  with  more  or  less 
laceration  of  the  brain  tissue.     These  cases  should  all  be  operated  upon  at 


106  SURGERY  OF  THE  HEAD 

once  for  the  purpose  of  cleansing  the  wound  and  relieving  any  irritation  of 
the  brain  from  the  depressed  fragments.  In  these  cases  it  is  well  to  tampon 
the  wound  full  with  sterile  gauze,  at  once,  so  as  to  prevent  the  introduction  of 
any  septic  material  into  the  wound  during  the  process  of  washing  and  shaving 
the  scalp.  After  the  scalp  has  been  disinfected  the  gauze  is  removed  from  the 
wound  and  the  skin  wound  is  enlarged  so  as  to  thoroughly  exposed  the  injured 
skull.  The  depressed  bone  should  be  raised  and  any  loose  pieces  of  bone 
should  be  removed,  as  the  patient  is  less  liable  to  suli'er  from  late  complica- 
tions, such  as  epilepsy,  than  when  the  loose  fragments  are  left  in  place.  After 
the  bone  has  been  elevated  and  loose  fragments  removed,  the  wound  should  be 
irrigated  with  normal  saline  solution.  Any  hemorrhage  from  the  brain  should 
be  controlled  by  placing  a  fine,  catgut  ligature,  or  by  tamponing  the  injured 
area  with  iodoform  gauze  and  leaving  it  in  place  for  forty-eight  hours.  If 
there  is  no  hemorrhage  from  the  brain,  the  dura  should  be  sutured  with  cat- 
gut. The  wound  is  drained  with  a  few  strands  of  silk-worm-gut  or  gutta 
percha  tissue. 

PUNCTURED  WOUNDS  OF  THE  SKULL 

These  cases  should  all  be  treated  by  operation,  which  consists  in  enlarging 
and  disinfecting  the  wound  and  controlling  any  hemorrhage  present.  In  case 
of  a  bullet  being  lodged  in  the  brain,  it  should  be  removed  if  it  is  situated 
near  the  surface  of  the  brain  and  can  be  located  easily.  On  the  other  hand  if 
it  cannot  be  seen,  or  located  by  gentle  probing,  it  had  best  be  left  alone  as  it 
is  not  apt  to  have  any  influence  upon  the  patient's  immediate  recovery.  Later 
on  if  the  patient  develops  any  symptoms  which  can  be  attributed  to  the  pres- 
ence of  the  bullet,  it  can  be  located  by  the  X-ray  and  then  be  removed  with 
comparative  safety. 

FRACTURES  OF  THE  BASE  OF  THE  SKULL 

The  diagnosis  of  fractures  of  the  base  of  the  skull  is  often  a  difficult  matter. 
These  fractures  usually  involve  the  petrous  portion  of  the  temporal  bone,  and 
hemorrhage  from  the  ear,  the  mouth  and  the  nose  may  be  looked  upon  as  a 
fairly  accurate  diagnostic  sign.  In  the  absence  of  this  hemorrhage  it  is  impos- 
sible to  differentiate  simple  concussion  or  laceration  of  the  brain  from  a  frac- 
ture of  the  base  of  the  skull.  The  diagnosis  between  these  conditions  is,  how- 
ever, of  not  so  much  importance,  because  the  same  expectant  treatment  should 
be  carried  out  in  either  case,  unless  the  patient  develops  signs  of  intra-cranial 
pressure. 

The  mortality  in  basal  fractures  is  high  and  probably  always  will  be, 
because  many  of  these  cases  succumb  within  the  first  few  hours  from  primary 
shock  and  brain  laceration.  These  patients  have  an  immediate  complete  coma, 
pupils  fixed,  stertorous  breathing  and  complete  muscular  relaxation,  and  may 
he  looked  upon  as  being  primarily  fatal. 

The  next  class  comprises  those  in  which  the  symptoms  are  not  so  severe, 
but  which  also  have  a  rather  high  mortality.  In  these  cases  the  coma  is  not 
so  profound,  the  muscles  are  not  completely  relaxed,  the  pupils  still  react,  the 
breathing  is  not  so  stertorous,  and  the  pulse  is  slow,  full  and  strong.  A  spinal 
puncture  should  be  made,  and  if  there  is  found  to  be  much  increased  intra- 
cranial pressure  a  trephining  is  indicated,  making  a  Gushing  decompression 
operation. 

There  is  another  group  of  cases  in  which  the  symptoms  are  more  mild. 
The  patient  may  retain  complete  consciousness,  or  nearly  so.     There  may  be 


SURGERY  OF  THE  HEAD  107 

an  impairment  of  one  or  more  of  the  cranial  nerves,  and  unequal  pupils,  but 
nothing  indicating  any  alarming  intra-cranial  lesion.  The  progress  in  this 
group  is  very  good  and  they  should  be  treated  expectantly. 

There  is  another  group  in  which  a  decompression  operation  is  definitely 
indicated.  It  is  in  those  cases  of  fracture  of  the  base  in  which  at  first  the 
injury  is  apparently  not  severe,  and  then  there  is  a  gradual  or  sudden  increase 
of  symptoms  giving  definite  signs  of  an  increasing  intra-cranial  pressure.  It 
is  probable  that  quite  a  number  of  these  cases  can  be  saved  by  the  decompres- 
sion operation. 

TUMORS  OF  THE  SKULL 

Tumors  of  the  skull,  which  result  from  invasion  of  tumors  of  the  scalp,  are 
the  only  ones  that  we  have  operated  with  permanent  recovery  of  the  patient. 
In  these  instances  the  most  satisfactory  results  have  been  obtained  by  remov- 
ing the  tumor  of  the  scalp,  together  with  a  large  area  of  surrounding,  appar- 
ently healthy  tissue,  and  then  applying  to  the  surface  of  the  entire  area  of 
exposed  skull,  and  also  to  the  edges  of  the  scalp  wound,  large  cautery  irons 
heated  to  read  heat,  being  careful,  however,  not  to  leave  the  iron  in  contact  at 
any  one  point  long  enough  to  cook  the  underlying  meninges  or  brain.  The 
Paquelin  cautery  does  not  hold  a  sufficient  amount  of  heat  to  be  of  as  much 
use  for  this  purpose  as  the  large  cautery  irons,  preferably  ordinary  soldering 
irons,  heated  in  a  large  gas  or  alcohol  flame. 

A  dry  dressing  is  then  applied  to  the  wound,  which  is  later  dressed  anti- 
septically  until  the  granulation  tissue  causes  the  sequestrum  to  loosen,  so  that 
it  may  be  removed  easily.  Then  the  entire  surface  is  covered  with  Thiersch 
grafts. 

PRIMARY  TUMORS  OF  THE  SKULL 

AVhen  these  are  quite  circumscribed  they  should  be  removed  with  the  over- 
lying skin  and  the  underl3'ing  dura;  at  least  two  cm.  of  skin  should  be  removed 
in  every  direction  beyond  the  edge  of  the  tumor. 

Personally,  we  have  never  encountered  any  primary  tumors  of  the  skull 
in  which  it  was  possible  to  make  a  pomplete  removal  of  the  growth  by  this, 
or  by  any  other  method,  but  this  does  not  make  such  a  condition  impossible, 
and  it  is  quite  conceivable  to  obtain  permanent  results  in  cases  coming  under 
treatment  reasonably  early. 

TUBERCULOSIS  OF  THE  SKULL 

This  condition  is  not  very  uncommon  and  the  results  of  surgical  treatment 
are  relatively  favorable  if  two  requirements  are  observed,  viz.,  1st,  careful 
removal  of  every  portion  of  the  infected  tissue,  and,  2nd,  careful  control  of 
the  diet  and  hygiene  of  the  patient  after  the  operation. 

In  these  cases  one  should  never  attempt  the  removal  of  the  diseased  tissue 
by  means  of  the  curette  through  the  sinuses  in  the  scalp,  a  method  which  had 
been  practised  unsuccessfully  in  every  case  that  has  come  under  our  care  to  the 
present  time.  If  a  radical  operation  is  not  feasible  for  the  time  being,  the 
patient  should  be  placed  under  careful  dietetic  and  hygienic  treatment  tem- 
porarily and  the  sinuses  should  be  injected  full  of  Beck's  bismuth  paste,  con- 
sisting of  one  part  of  bismuth  subnitrate  and  two  parts  of  yellow  vaseline. 
This  should  be  repeated  from  one  to  three  times  per  week,  according  to  the 
progress  of  the  case. 


108  SURGERY  OF  THE  HEAD 

The  discharge  from  the  sinuses  will  become  aseptic  after  a  short  time  and 
complete  healing  may  ensue,  although  our  personal  experience  with  the  paste 
in  this  part  of  the  body  has  not  been  sufficient  to  determine  this  with  certaintj'. 

Technique.  It  is  highly  important  to  make  a  large  incision  in  order  that 
every  portion  of  the  diseased  bone  may  be  exposed  after  the  periosteum  has 
been  retlected,  together  with  the  skin  Bap.  Beginning  at  the  opening  of  any 
one  of  the  sinuses  of  the  skull,  the  outer  table  is  chiseled  away  with  a  very 
sharp  carpenter's  chisel.  In  order  to  find  all  portions  of  the  diseased  bone  it 
is  important  to  observe  the  granulation  tissue  projecting  from  the  cut  surface 
of  the  bone  after  carefullj^  sponging  away  the  blood.  Sharp,  gnawing,  bone 
forceps  are  very  useful  in  this  operation,  but  there  is  no  instrument  of  as  much 
value  as  the  sharp  carpenter's  chisel  and  gouge. 

After  all  of  the  sinuses  have  been  followed  and  every  portion  of  the  infected 
tissue  has  been  cut  or  curetted  away  so  that  there  is  at  no  point  any  granu- 
lation tissue  to  be  found,  the  surface  is  dried  and  then  saturated  for  ten  minutes 
with  95  per  cent,  carbolic  acid ;  then  it  is  covered  with  strong  alcohol  until 
the  white  color  caused  by  the  carbolic  acid  has  entirely  disappeared,  after 
which  it  is  thoroughly  covered  with  strong  compound  tincture  of  iodine.  A 
little  silkworm  gut  or  rubber  tissue  drain  is  placed  and  the  wound  is  sutured. 

In  the  rare  cases  in  which  the  overlying  scalp  has  been  destroyed  by  the 
disease  a  sufficient  amount  of  the  surrounding  tissue  is  removed  by  the  actual 
cautery  to  insure  a  complete  removal  of  all  of  the  diseased  tissue  and  then  the 
entire  surface  is  covered  with  Thiersch  skin  grafts,  after  the  bone  surface  has 
become  covered  with  granulation  tissue. 

CLOSURE  OF  BONY  DEFECTS  IN  THE  SKULL 

In  case  a  considerable  portion  of  the  skull  has  been  entirely  removed,  it 
may  become  desirable  to  close  this  defect  in  order  to  protect  the  patient  against 
an  accidental  injury  of  the  exposed  portion  of  the  brain.  This  becomes  neces- 
sary only  in  cases  in  which  the  defect  is  very  large,  or  in  which  it  gives  rise 
to  some  form  of  annoyance  to  the  patient.  The  latter  may  feel  a  sense  of 
insecurity  or  he  may  be  annoyed  by  extreme  heat  or  cold,  or  there  may  be  a 
sensation  of  pain,  or  the  constant  pulsation  of  the  area  may  give  rise  to  a  feel- 
ing of  nervousness,  or  the  irritation  may  occasion  attacks  of  epilepsy.  In 
either  case  the  defect  may  be  closed  by  the  insertion  of  a  foreign  substance 
between  the  scalp  and  the  dura,  such  as  a  thin  plate  of  celluloid,  which  may 
be  boiled  and  cut  the  exact  shape  of  the  defect,  with  a  sufficient  margin  to 
hold  the  plate  when  inserted  underneath  the  rim  of  the  defect  in  the  skull.  If 
such  a  plate  is  implanted  aseptically  it  will  remain  for  an  indefinite  period  of 
time  without  giving  rise  to  any  annoyance.  AVe  have  used  such  plates  in  a 
number  of  cases  with  perfect  satisfaction.  It  must  be  remembered,  however, 
that  in  cases  of  epilepsy  the  number  of  cures  from  the  use  of  such  a  plate  is 
relatively  very  small. 

An  autoplastic  bony  closure  may  be  accomplished  by  cutting  an  oval  flap 
of  the  scalp  directly  along  the  side  of  the  defect  with  a  pedicle  sufficient  to 
supply  circulation :  then  cutting  a  second  flap  of  the  same  shape  directly  cov- 
ering'the  defect  and  having  its  pedicle  in  the  opposite  direction  from  the  one 
first  made.  The  second  flap  is  dissected  loose,  leaving  the  dura  in  place.  The 
latter  is  then  loosened  from  its  attachment  to  the  rim  of  the  opening  and  with 
a  thin,  broad  chisel  a  thin  layer  of  the  skull  underlying  the  first  flap  is  chiseled 
loose  and  left  in  contact  with  the  flap.  The  latter  is  then  transplanted  over 
the  defect  in  the  skull  and  sutured  in  place,  and  the  second  flap  is  then  sutured 
into  the  space  from  which  the  first  flap  has  been  removed.    In  this  manner  all 


SURGERY  OF  THE  HEAD 


109 


portions  of  the  scalp  will  remain  covered  with  hair  and  the  bone  carried  with 
the  first  flap  will  efi'ectually  close  the  defect  in  the  skull. 

This  operation  has  usually  been  performed  by  removing  the  scalp  from  the 
surface  of  the  defect  and  transplanting  a  flap  from  a  neighboring  portion  of 
the  skull  and  then  covering  the  defect  with  skin- grafts,  but  the  method  which 
has  just  been  described  is  very  much  more  satisfactory,  as  it  does  not  leave 
a  portion  of  the  scalp  without  its  hairy  covering. 

For  a  number  of  years  we  have  cut  away  the  cicatricial  tissue  covering  the 
brain  at  the  point  of  injury.  To  cover  the  defect  we  have  then  cut  a  piece 
out  of  the  fascia  lata  of  exactly  the  right  size  and  containing  a  layer  of  fat 


Cask  of  Traumatic  Epilepsy  Due  to  Old  Organized  Blood  Clot. 

(b)   Operative  Trephine  Scar. 


(a)  Original  Scar,  and 


2  mm.  in  thickness.  This  we  have  sutured  so  as  to  place  the  fat  in  contact 
with  the  brain  by  means  of  six  or  eight  fine  catgut  sutures.  In  most  cases 
this  will  furnish  a  good  protection  for  the  underlying  brain,  even  if  no  portion 
of  the  skull  has  been  transplanted. 

CEREBRAL  LOCALIZATION 

In  order  to  intelligently  approach  surgical  conditions  within  the  cavity  of 
the  skull,  affecting  portions  of  the  brain,  it  is  absolutely  necessary  to  have  a 
clear  conception  of  cerebral  localization. 

"We  have  personally  always  depended  upon  some  one  of  our  colleagues 
whose  opinion,  from  a  neurological  standpoint,  was  so  vastly  superior  to  our 
own  that  we  have  never  felt  called  upon  to  rest  upon  our  own  judgment  in 
the  matter  of  locating  cerebral  conditions  independently. 

We  have,  however,  always  confirmed  these  diagnoses  before  opening  the 


110 


SURGERY  OF  THE  HEAD 


skull,  simply  for  the  purpose  of  having  a  reasonable  basis  upon  which  to  share 
the  responsibility. 


Diagram  Showing  Areas  of  Cerebral  Localization. 


For  practical  purposes  it  seems  best  to  obtain  a  mental  picture  of  the  entire 
brain,  and  to  associate  the  various  areas  "v^ith  their  functions,  and  then  to 
transfer  these  areas  to  the  surface  of  the  skull. 


Diagram  Showing  Areas  of  Cerebral  Localization. 

The  accompanying  drawings  by  Prof.  Chas.  K.  Mills,  are  exceedingly  simple 
and  clear,  and  we  have  found  them  most  useful  in  our  own  clinical  work. 


SURGERY  OF  THE  HEAD        .  Ill 

There  are  certain  general  facts  concerning  cerebral  localization  which  must 
always  be  borne  in  mind  in  diagnosing  brain  lesions,  which  are,  however,  so 
well  known  that  it  is  scarcely  proper  to  mention  them  in  this  place.  "We  refer 
particularly  to  the  fact  that,  with  the  exception  of  certain  muscles  like  the 
orbiculares  oculi,  those  of  mastication,  the  larynx,  the  pharynx,  etc.,  the 
muscles  of  the  body  are  controlled  by  the  motor  areas  of  the  opposite  cerebral 
hemisphere.  There  may,  however,  be  a  tumor,  abscess,  or  blood  clot,  in  one 
hemisphere,  exerting  a  sufficient  amount  of  pressure  transversely  upon  the 
other  side  to  cause  symptoms  originating  in  the  opposite  hemisphere,  so  that 
symptoms  of  paralysis  in  these  rare  cases  will  be  found  on  the  side  on  which 
the  brain  lesion  exists. 

It  is  further  important  to  remember  that  these  areas  of  localization  are  not 
definitely  circumscribed,  but  that  they  overlap  each  other.  ^ 

TREPHINING  FOR  THE  CURE  OF  EPILEPSY 

In  cases  in  which  epilepsy  follows  fracture  of  the  skull  and  in  which  it  is 
possible  to  determine  positively  from  local  symptoms  that  there  is  a  definite 
point  in  the  cerebrum  which  is  being  irritated  by  some  condition  resulting 
from  the  fracture,  it  may  be  proper  to  remove  a  portion  of  the  skull  overlying 
the  area  which  has  been  determined  and  to  remove  any  irritating  substance  it 
may  be  possible  to  discover.  Occasionally  an  exostosis  has  developed  from  the 
line  of  fracture  in  the  form  of  a  sharp  spicule  of  bone,  or  a  fragment  may  have 
been  displaced  at  the  time  of  the  original  injury  and  may  extend  into  the  sub- 
stance of  the  brain,  or  a  small  cyst  may  have  formed  on  the  under  surface  of 
the  dura  or  the  latter  may  be  markedly  thickened,  or  there  may  be  a  consider- 
able amount  of  cicatricial  tissue  in  the  brain  substance,  resulting  from  the 
healing  of  a  tear. 

All  of  these  may  readily  be  relieved  by  excision,  but  unfortunately  this 
does  not  result  in  a  cure  in  many  of  the  cases  of  epilepsy  which  are  unques- 
tionably traumatic  in  origin. 

The  trephining  should  be  made  over  the  site  of  the  previous  trauma,  and 
the  bone  removed  during  the  operation  should  be  discarded.  There  seems  to 
be  less  likelihood  of  having  a  recurrence  than  when  the  bone  has  been  replaced. 
If  it  has  been  necessary  to  excise  a  portion  of  the  dura,  this  can  be  replaced 
by  putting  a  piece  of  fat  or  fascia  lata  between  the  brain  and  scalp  where  the 
dura  has  been  removed. 

Importance  of  after-treatment.  In  the  after-treatment  of  these  cases  that 
have  been  treated  surgically  it  is  important  to  insist  upon  good  hygiene  and 
dietetic  care  for  a  long  period  of  time.  It  is  also  well  to  give  these  patients 
as  nearly  as  possible  a  salt-free  diet  and  to  have  them  use  a  very  small  amount 
of  bromide  of  soda,  in  place  of  table  salt,  on  their  food.  All  excitement,  over- 
work, exposure  to  heat,  and  every  other  form  of  physical  and  mental  irritation 
should  be  avoided.  The  use  of  thyroid  extract  may  be  tried  by  giving  from 
three  to  four  doses  daily  of  three  to  five  grains. 

We  have  used  this  form  of  treatment  in  many  cases,  and  although  its  results 
have  been  disappointing  time  and  again,  still  there  have  been  a  sufficient  num- 
ber in  which  the  results  were  satisfactory  to  make  the  effort  worth  while. 

This  is  true  especially  where  we  have  been  able  to  direct  the  diet  and 
hygiene  of  the  patient  subsequent  to  the  operation. 

Many  of  these  patients  have  acquired  careless  or  erratic  habits  of  life,  and 
especially  unfavorable  habits  of  diet,  both  as  regards  time  of  eating  and  quan- 
tity and  character  of  food.  We  have  observed  patients  who  remained  perfectly 
well  for  months  or  years  who  had  a  recurrence  of  an  epileptic  seizure  after 
eating  an  unreasonable  amount,  or  after  eating  a  large  meal  when  exhausted 
after  a  day's  labor.  One  of  these  remained  well  until  he  worked  beyond  his 
strength  for  a  number  of  days  in  the  hay  field,  after  having  been  well  for  two 


112 


SURGERY  OF  THE  HEAD 


years  following  an  operation  for  the  relief  of  a  depressed  fracture  of  the  skull. 
This  ease  had  suffered  from  epilepsy  for  several  years  previous  to  the  operation. 
It  seems  clear  that  although  the  local  irritation  in  the  cortex  may  have 
been  relieved  by  the  operation,  any  one  of  a  number  of  correlating  influences 
affecting  the  patient's  general  condition  may  be  the  cause  of  a  recurrence, 
hence  the  wisdom  of  careful  control  of  the  patient  after  operation. 


Hydrocephalus  with  Jackscnian  Type  of  Epilepsy  in  a  10-Year-Old  Boy. 
Relieved  by  Decompression. 

IDIOPATHIC  EPILEPSY 

Since  Kocher  advanced  the  theory  that  an  increased  intracranial  pressure 
was  the  important  etiological  factor  in  idiopathic  epilepsy  there  has  been  some 
hope  of  giving  relief  surgically  to  some  of  these  unfortunate  cases.  During 
the  past  few  years  quite  a  number  of  surgeons  have  made  some  form  of  a 
decompression  operation  in  these  cases  with  a  varying  degree  of  success. 

Kocher  makes  a  decompression  in  the  right  fronto-parietal  region  by  first 
making  a  large  flap  of  scalp  with  pedicle  downwards,  then  excising  a  large 
area  of  bone  in  the  fronto-parietal  region.  The  dura  is  carefully  excised,  the 
area  removed  being  a  little  smaller  than  the  opening  made  in  the  skull.  The 
scalp  flap  is  then  replaced  and  sutured. 

During  the  past  two  years  the  authors,  in  addition  to  making  a  decompres- 
sion operation,  have  followed  the  method  of  Kirscher  of  replacing  the  excised 
dura  by  a  flap  of  fascia  lata.  The  technique  is  as  follows :  A  large  scalp  flap 
is  made  right  over  fronto-parietal  region  with  its  base  downwards.  The  skull 
is  opened  and  the  bone  removed  from  the  fronto-parietal  region  low  down. 
The  decompression  should  be  made  as  near  the  base  of  the  brain  as  possible, 
so  as  to  keep  away  from  the  motor  areas.  The  dura  is  excised  from  this  entire 
area,  leaving  about  one  cm.  of  dura  inside  of  the  skull  opening. 

A  flap  of  fascia  lata,  with  a  little  subcutaneous  fat,  the  size  of  the  bony 


SURGERY  OF  THE  HEAD 


113 


defect,  is  removed  from  the  patient's  thigh.,  and  placed,  fat  side  downwards, 
over  the  dural  defect.  This  fascia  overlaps  the  dura  all  around  about  one  cm., 
to  which  it  is  attached  by  placing  a  few  cat-gut  sutures.  The  scalp  flap  is  then 
replaced  and  sutured.  Too  short  a  time  has  elapsed  to  give  any  final  con- 
clusion, but  so  far  the  results  by  this  method  have  been  quite  satisfactory.  The 
same  after-treatment  should  be  carried  out  in  these  cases,  as  previously 
described  in  connection  with  operation  for  traumatic  epilepsy. 

TUMORS  OF  THE  BRAIN 

The  removal  of  a  fibroma,  gumma,  or  cysts  from  the  brain  is  frequently  fol- 
lowed by  permanent  recovery  of  the  patient,  and  as  it  is  usually  impossible  to 


HoGLUND  's  Electric  Eotary  Chain-Saw. 


make  a  differential  diagnosis  between  these  and  malignant  growths  an  attempt 
at  their  removal  is  of  course  justifiable,  because  the  consequent  pressure  from 
benign  growths  will  result  seriously  to  the  patient,  even  if  it  does  not  shortly 
destroy  him.  Therefore  the  patient  who  is  suffering  from  a  non-malignant 
tumor  has  everything  to  gain  from  operative  treatment,  while  the  one  who 
suffers  from  the  presence  of  a  malignant  growth  has  nothing  to  lose  and,  as 
will  be  presently  indicated  in  the  discussion  of  the  decompression  operation, 
even  this  class  of  patients  has  much  to  gain. 

Gushing,  Mills,  Krause  and  Horslej^  have  demonstrated  the  possibility  of 
exact  localization  so  constantly  and  so  many  times  that  one  can  usually  be 
positive  concerning  the  location  of  cerebral  tumors.    In  our  experience  Roth- 


114  SURGERY  OF  THE  HEAD 

stein  has  been  able  to  indicate  the  precise  location  of  cerebral  growths,  so 
that  it  has  been  possible  for  us  to  make  an  osteoplastic  flap  in  each  instance 
from  -which  the  growth  could  be  reached. 

Experience  and  special  training.  At  this  point  it  may  be  well  to  state  that 
it  is  not  proper  to  undertake  this  operation  unless  a  surgeon  has  had  expe- 
rience in  the  capacity  of  assistant  to  a  skillful  and  careful  master.  It  is  quite 
different  from  operating  for  cerebral  pressure,  due  to  the  presence  of  a  blood- 
clot  caused  by  hemorrhage  from  a  torn  vessel,  which  is  really  an  emergency 
operation  that  cannot  wait  for  a  surgeon  with  special  training. 

Technique.  Many  of  these  patients  lack  resistance  and  consequently  the 
surgeon  with  the  greatest  experience  and  skill,  and  the  best  judgment,  is  none 
too  well-equipped  for  performing  a  successful  operation.  In  many,  it  is  best 
to  make  the  skin  and  bone  flap  at  the  first  operation,  and  then,  a  few  days 
later,  when  the  patient  has  recovered  from  the  shock  of  this  step,  to  complete 
the  work.  In  the  meantime  a  piece  of  aseptic  gauze  is  placed  underneath  the 
flap  and  the  latter  is  held  in  place  by  means  of  a  few  sutures  and  the  entire 
area  covered  with  an  aseptic  dressing. 

"With  some  experience  it  is  possible  to  determine  which  cases  should  be 
treated  in  one  and  which  in  two  stages. 

The  trephining  may  be  accomplished  by  means  of  an  ordinary  trephine  and 
the  bone  flap  cut  out  by  a  DeVilbiss  forceps,  as  previously  described,  or  by 
using  one  of  the  various  electrical  devices  now  in  use,  such  as  Hoglund's  elec- 
trically propelled  rotary  chain-saw  and  automatic  trephine,  which  we  have 
found  to  be  very  satisfactory. 

The  rotary  chain-saw  is  so  arranged  that  it  will  cut  a  circular  flap  as  small 
as  two  inches  in  diameter.  The  trephine  is  connected  to  the  driving  shaft  by 
means  of  an  automatic  clutch,  so  that  when  the  trephine  is  almost  through  the 
bone  the  clutch  will  automatically  disengage  itself  and,  rotating  the  trephine, 
leave  a  thin,  transparent  bone  plate  from  the  vitreous  part  of  the  skull.  This 
absolutely  prevents  injury  to  the  dura  mater  when  trephining.  The  chain- 
saw  is  now  introduced  through  the  trephine  opening  and  a  large  or  small 
circular  piece  of  bone  is  cut  as  desired.  The  bone  edge  can  be  made  either 
straight  or  bevelled  by  tilting  the  instrument  to  any  angle  desired. 

In  brain  operations  hemorrhage  is  one  of  the  most  troublesome  features. 
Only  a  few  of  the  bleeding  vessels  can  be  controlled  with  hemostatic  forceps 
and  ligatures. 

The  hemorrhage  from  the  scalp  can  be  controlled  by  encircling  the  skull 
with  a  tight  rubber  band  approximately  along  Reid's  base  line.  This  con- 
strictor must  be  very  tight,  or  it  will  increase  the  venous  oozing,  making  that 
more  troublesome  than  without  anything. 

Crile  has  recently  devised  special  needle  clamps  to  be  used  in  controlling 
this  hemorrhage,  which  clamps  are  applied  by  means  of  a  special  forcep  for 
that  purpose.  The  clamps  are  actuated  by  powerful  springs  and  control  the 
hemorrhage  perfectly. 

If  hemorrhage  from  the  edge  of  the  skull  is  troublesome  it  may  be  con- 
trolled by  crushing  the  edges  of  the  bases  with  heavy  bone  forceps,  or  by  using 
Horsley's  bone  wax,  the  composition  of  which  is:  beeswax,  7  parts;  almond 
oil,  1  part ;  salicylic  acid,  1  part.  A  little  of  this  wax  pressed  against  the  bleed- 
ing diploe  will  readily  control  hemorrhage  from  this  source. 

Most  of  the  hemorrhage  from  the  brain  must  be  controlled  with  gauze  pads 
wrung  out  of  hot,  normal  salt  solution.  Even  very  severe  oozing  of  blood  from 
the  cut  brain  surface  can  usually  be  checked  by  holding  one  of  these  pads  in 
contact  with  the  bleeding  surface  for  a  period  of  five  minutes.  If  this  does  not 
suffice  in  giving  a  sufficient  amount  of  freedom  from  bleeding,  the  head  of  the 
table  should  be  elevated  in  order  to  place  the  body  at  an  angle  of  from  forty 


SUEGERY  OF  THE  HEAD  115 

to  sixty  degrees  Trith.  the  horizontal  plane.  If  this  does  not  answer,  the  wound 
should  be  tamponed  with  sterile  gauze  and  the  operation  completed  after  an 
interval  of  several  days. 

After  the  tumor  or  gumma  has  been  enucleated  the  cavity  should  be  tam- 
poned with  a  gauze  pad  wrung  out  of  hot,  normal  salt  solution,  and  this  should 
be  left  in  place  for  at  least  five  minutes.  If  hemorrhage  is  seen  to  have  ceased 
when  the  tampon  is  removed,  the  dura  and  skin-flaps  should  be  closed,  with  the 
exception  of  one  angle.  If  hemorrhage  has  not  ceased  the  cavity  should  again 
be  tamponed  with  an  aseptic  gauze  strip  and  one  strand  should  be  passed  out 
of  the  angle  of  the  wound,  which  is  to  be  closed  as  above.  A  piece  of  gutta 
percha  tissue  should  be  placed  about  the  part  of  the  gauze  passing  through  the 
dura  and  the  scalp  in  order  to  facilitate  its  removal  a  few  days  later. 

DECOMPRESSION  OPERATION 

In  many  cases  in  which  a  tumor  cannot  be  removed  and  in  which  the  patient 
suffers  from  pressure  symptoms,  such  as  headache,  dizziness,  nausea,  or  eye 
symptoms,  as  indicated  by  impaired  vision  and  by  the  presence  of  choked  disk 
on  ophthalmoscopic  examination,  he  may  be  greatly  benefited  by  the  removal 
of  a  large  portion  of  the  skull  on  one  or  both  sides. 

A  flap  is  made  preferably  over  the  temporal  and  parietal  region  low  down 
near  the  base  of  the  skull.  It  should  include  the  scalp  and  the  skull  together 
with  the  dura.  If  an  exploration  seems  indicated,  the  dura  is  not  primarily 
removed,  but  a  crucial  incision  is  made  in  the  dura,  which  is  later  closed  with 
catgut  sutures,  if  a  removable  tumor  is  found,  but  otherwise  it  is  cut  away  at 
once.  The  bone  flap  is  removed  entirely  and  the  skin  flap  is  closed,  with  the 
exception  of  a  space  of  about  one  cm.  at  one  angle.  TTe  have  repeatedly  ob- 
served a  marked  subjective  improvement  in  the  vision  in  these  instances  and 
a  disappearance  of  all  of  the  other  symptoms  due  to  cerebral  pressure. 

In  most  cases  the  patients  have  remained  comfortable  after  this  operation 
until  they  have  suddenly  died  from  hemorrhage  or  from  a  perforation  of  a 
lateral  ventricle,  but  in  each  one  the  patient  and  his  friends  have  agreed  with 
us  in  the  supposition  that  the  operation  had  been  of  marked  benefit  to  the 
sufi^erer. 

In  cases  in  which  it  is  plain  from  the  start  that  nothing  can  be  done  except^ 
a  decompression  operation,  it  is  perfectly  proper  that  this  be  undertaken  by  a 
surgeon  of  ordinary  skill  and  without  especial  experience,  but  this  is  never 
proper  in  cases  in  which  a  surgeon  with  greater  skill  might  be  justified  in 
removing  the  tumor. 

» 
ABSCESS  OF  THE  BRAIN 

What  has  been  said  with  regard  to  tumors  of  the  brain,  so  far  as  localiza- 
tion and  approach  through  the  skull  are  concerned,  may  also  be  applied  to 
cerebral  abscess.  In  these  cases  there  is,  however,  usually  a  history  of  sup- 
puration, most  commonly  in  the  middle  ear  and  mastoid  cells,  and  occasionally 
in  the  cavities  connected  with  the  nose. 

Nausea  is  usually  one  of  the  prominent  symptoms  and  there  is  often,  but 
not  always,  a  rise  in  temperature  at  some  period  during  the  day. 

Due  to  the  scarcity  of  lymphatics  in  the  brain,  an  abscess  located  there  may 
be  unaccompanied  by  either  fever  or  leucocytosis. 

After  exposing  the  dura  by  reflecting  a  bone  flap  there  may  be  an  absence 
of  pulsation  and  the  dura  may  be  edematous,  showing  that  the  abscess  is 
superficial.  In  this  event  a  simple  incisioj^,  with  the  insertion  of  a  soft  rubber 
drainage  tube,  will  suffice. 

Should  the  abscess  not  be  superficial  the  deep  tissues  may  be  explored  by 


116 


SURGERY  OF  THE  HEAD 


the  use  of  an  exploring  needle,  with  a  closed,  moderately-sharp  end  and  a 
fair-sized  hole  in  the  side  near  the  end.  It  should  carry  an  obturator  in  order 
to  prevent  the  brain  tissue  from  clogging  the  canula.  From  time  to  time  this 
should  be  removed  and  an  aspirating  syringe  attached ;  if  pus  escapes  an 
incision  should  be  made  along  the  side  of  the  exploring  trocar  and  a  soft- 
rubber  drainage  tube  inserted.  A  notch  should  be  cut  in  the  bone  flap  suffi- 
ciently large  to  prevent  compression  of  the  tube,  which  should  be  passed  out 
at  this  point  and  the  wound  closed,  sufficient  space  being  left  for  satisfactory 
drainage.  Irrigation  should  not  be  employed.  The  drainage  tube  should  be 
left  in  place  until  the  discharge  of  pus  has  ceased. 


r 


Cranial  Areas  for  Osteoplastic  Operations. 

It  should  be  borne  in  mind  at  this  point  that  by  far  the  most  important 
duty  of  the  surgeon  is  to  prevent  the  formation  of  cerebral  abscesses  by  early 
radical  treatment  of  suppuration  wherever  it  may  occur,  but  especially  sup- 
puration of  the  middle  ear  and  of  the  mastoid  cells. 

Decompression  operation.  It  has  been  recommended  by  Dreyer  that  nu- 
merous trephine  openings  be  made  for  the  purpose  of  securing  decompression 
and  that  in  case  conditions  are  found  opposite  any  one  of  these  openings 
which  indicates  that  a  larger  opening  is  required,  either  for  the  removal  of  a 
growth  or  drainage  of  an  abscess,  then  the  intervening  bridges  may  be  cut  and 
the  opening  enlarged  to  any  size  desired. 


SURGERY  OF  THE  HEAD  117 

RESECTION  OF  THE  MASTOID  CELLS 

Patients  suffering  from  infection  of  the  mastoid  process  usually  give  a 
preliminary  history  of  some  infectious  disease  affecting  the  tonsils.  This  is 
followed  by  an  infection  of  the  cavity  of  the  middle  ear.  The  abscess  of  .the 
middle  ear  may  have  been  drained  spontaneously  by  a  perforation  of  the 
drum,  or  the  latter  may  have  been  incised,  but  there  is  usually  a  history  of 
recurrence  of  this  infection  or  a  continuous  infection  indicated  by  the  pres- 
ence of  interrupted  or  continuous  discharge  from  the  ear.  Following  this 
pain  appears  behind  the  ear  in  the  region  of  the  mastoid  process.  Frequently 
this  pain  subsides  "when  the  discharge  reappears,  indicating  that  drainage  has 
been  established  from  the  mastoid  process  through  the  middle  ear.  In  other 
cases  the  pain  steadily  increases  and  is  presently  followed  by  the  occurrence 
of  edema  over  the  region  of  the  mastoid  process,  which  may  extend  down- 
wards upon  the  neck  along  the  course  of  the  deep  jugular  vein.  In  rare  in- 
stances there  may  be  fluctuation  in  the  region  of  the  mastoid  process,  or  even 
perforation  of  the  abscess,  but  usually  the  resistance  of  the  periosteum  cover- 
ing this  process  is  sufficient  to  prevent  these  evidences  from  appearing. 

Still  later  the  patient  may  suffer  from  diffuse  headaches  extending  over 
a  more  or  less  extensive  region,  usually  radiating  from  the  site  of  the  infected 
process.  Still  later  the  patient  may  become  comatose,  or  nausea  and  vomiting 
may  appear,  which  may  be  followed  sooner  or  later  by  coma  and  death.  The 
explanation  of  the  condition  described  lies  in  the  fact  that  the  infection  has 
extended  from  the  cavity  of  the  middle  ear  into  the  mastoid  cells.  It  has 
then  progressed  outward  to  the  periosteum,  or  through  this,  or  it  has  ex- 
tended inward  underneath  the  dura  and  has  caused  a  more  or  less  diffuse 
meningitis,  sometimes  accompanied  by  a  subdural  abscess,  or  it  may  have 
extended  into  the  brain — giving  rise  to  a  cerebral  abscess.  These  patients 
are  usually  seen  by  the  practitioner  before  the  infection  has  advanced  beyond 
the  mastoid  cells,  and  it  is  at  this  time  that  the  greatest  amount  of  benefit 
may  come  from  surgical  intervention.  At  this  time  the  operation  is  safe,  it 
can  be  performed  by  any  surgeon  with  ordinary  skill,  and  the  patient  is  not 
likely  to  suffer  secondarily  as  a  result.  It  is  quite  different  if  the  operation 
be  postponed  until  there  has  been  a  considerable  extension  of  the  infection.  In 
such  event  it  is  scarcely  proper  for  any  one  who  has  not  had  extensive  experi- 
ience  in  brain  surgery  to  operate  upon  these  patients,  and  even  with  the  greatest 
skill  the  proportion  of  recoveries  is  but  slight.  In  cases  operated  at  the  proper 
time,  that  is,  during  the  early  part  of  the  infection,  the  drainage  which  can 
easily  be  established  will  prevent  the  further  infection  of  the  deeper  structures, 
and  consequently  will  make  a  more  extensive  operation  unnecessary. 

It  would  seem  that  the  presence  of  pain,  together  with  even  a  slight  amount 
of  edema  in  the  region  of  the  mastoid  process,  the  pain  being  increased  upon 
pressure,  and  in  any  case  in  which  there  is  a  history  of  previous  infection  of 
the  middle  ear,  would  be  a  distinct  indication  for  an  operation. 

Technique.  A  sufficient  amount  of  hair  should  be  shaved  off  in  the  vicinity 
of  the  mastoid  process  to  prevent  annoyance  in  applying  the  dressings  later  on 
and  to  prevent  the  hair  from  interfering  with  the  progress  of  the  operation.  A 
vertical  incision  is  then  made  directly  behind  the  ear,  one  and  one-half  inches 
in  length,  whose  center  is  at  a  point  one-fourth  of  an  inch  behind  and  exactly 
on  a  level  with  the  upper  margin  of  the  external  auditory  meatus.  This  in- 
cision should  extend  down  through  all  the  tissues  to  the  bone.  The  periosteum 
is  carefullj'  reflected  and  in  this  manner  the  mastoid  process  is  exposed. 

If  the  points  which  have  just  been  mentioned  are  borne  in  mind,  the  oper- 
ation may  be  performed  with  safety  by  any  one,  the  opening  into  the  mastoid 
cells  being  made  by  means  of  an  ordinary  carpenter's  gouge  about  one-half 
inch  in  diameter. 


118  SURGERY  OF  THE  HEAD 

The  dangers  of  the  operation  are  in  opening  the  meninges  above,  or  in- 
vading the  sinus  behind,  but  if  the  operator  makes  his  initial  opening  in  the 
mastoid  process  at  a  point  on  a  level  with  the  upper  margin  of  the  external 
auditory  meatus  and  one-fourth  of  an  inch  behind  the  posterior  margin,  these 
dangers  will  be  entirely  avoided.  After  the  mastoid  cells  have  once  been 
entered  the  opening  can  easily  be  enlarged  by  chiseling  in  every  direction 
from  this  central  point.  The  mastoid  cells  will  be  found  to  contain  pus  in 
various  quantities  from  a  few  drops  to  one-half  a  drachm  or  more.  This  is 
carefully  sponged  away  and  the  external  avenue  enlarged  until  it  is  as  large 
in  every  direction  as  the  greatest  diameter  of  the  underlying  cavity,  so  that 
the  cavity  which  is  left  will  be  conical  in  shape,  with  the  base  of  the  cone 
directed  upward.  Care  should  be  taken  not  to  injure  the  branch  of  the  facial 
nerve  extending  along  the  edge  of  the  external  auditory  meatus,  but  this  can 
be  easily  done  by  simply  bearing  in  mind  the  anatomical  position  of  this  nerve 
and  working  away  from  it  with  the  chisel,  instead  of  toward  it.  The  cavity 
after  being  thoroughly  cleansed,  is  loosely  tamponed  with  gauze  and  a  dressing 
applied  over  it. 

The  dressing  should  be  renewed  at  first  every  day,  and  later  less  frequently, 
the  opening  in  the  mastoid  being  permitted  to  heal  from  the  bottom  by  granu- 
lation. In  advanced  cases,  and  in  those  in  which  the  infection  has  existed  for 
a  sufficient  time  to  insure  the  involvement  of  surrounding  tissues,  a  more  ex- 
tensive operation  is  indicated,  but  this  should  be  performed  only  by  those 
experienced  in  surgery  upon  the  skull,  as  the  dangers  of  causing  permanent 
injury  are  much  greater,  and  the  necessity  of  the  operation  is  not  so  urgent 
as  in  acute  mastoiditis ;  consequently  such  operation  may  safely  be  postponed 
until  the  proper  preparation  can  be  made.  The  conditions  are,  therefore, 
quite  opposite  in  acute  mastoiditis;  the  operation  being  simple,  safe  and 
strongly  indicated  at  once,  while  postponement  is  connected  with  great  danger. 
In  chronic  cases  the  operation  is  complicated,  difficult  and  dangerous,  while 
postponement  is  relatively  safe. 

MASTOID  OPERATION  IN  CHRONIC  CASES 

It  is  difficult  to  describe  this  operation  so  that  it  can  be  performed  safely 
by  one  who  has  neither  accomplished  it  upon  the  cadaver  nor  has  seen  it  done 
upon  the  living  subject,  and  we  believe,  therefore,  that  this  operation  is  not 
justifiable  unless  the  surgeon  has  performed  it  upon  the  cadaver. 

The  incision  is  the  same  as  in  the  operation  just  described;  the  periosteum 
is  then  stripped  away  toward  the  external  auditory  meatus  and  a  blunt  peri- 
osteotome  is  passed  down  between  the  bony  canal  of  the  external  auditory 
meatus  and  the  skin  lining  this  canal,  so  that  the  latter  is  loosened  down  to 
the  tympanum.  The  mastoid  antrum  is  then  opened,  as  described  in  the 
former  operation,  and  the  lower  layer  of  the  posterior  wall  of  the  bony 
portion  of  the  external  auditory  canal  is  removed  with  a  chisel,  so  that  the 
external  auditory  meatus  and  the  cavity  in  the  mastoid  form  a  continuous 
conical  opening.  The  cavity  of  the  middle  ear  is  then  opened  and  the  hammer 
and  anvil  are  removed  by  means  of  forceps.  Great  care  must,  of  course,  be 
exercised  to  protect  the  branch  of  the  facial  nerve  which  passes  through  the 
bony  wall  of  the  inner  half  of  the  antral  passage  obliquely  from  without  in- 
wards as  it  passes  the  inner  wall  and  roof  of  the  tympanum.  The  skin  lining 
the  external  auditory  meatus  is  then  split  longitudinally  and  spread  out  oyer 
the  surface  of  the  newly-formed  cavity  for  the  purpose  of  lining  this,  thus  in- 
creasing the  size  of  the  external  auditory  meatus  greatly.  It  is  held  in  place 
by  means  of  a  tampon  of  iodoform  gauze. 


SURGERY  OF  THE  HEAD  119 

Use  of  Beck's  bismuth  paste.  During  the  past  few  years  we  have  found 
that  cases  in  which  the  infection  extends  down  the  Eustachian  tube  at  the 
time  of  operation,  causing  a  reinfection  of  the  wound  and  a  consequent  re- 
tardation in  healing,  excellent  results  may  be  obtained  from  dressing  the 
cavity  with  Beck's  bismuth  paste,  consisting  of  one  part  of  bismuth  subnitrate 
and  two  parts  of  yellow  vaseline,  applied  daily  at  first  and  less  frequently 
later  on. 

Of  course,  by  invariably  removing  the  infected  tonsils  and  the  adenoids, 
which  are  located  about  the  osteum  of  the  Eustachian  tube,  conditions  are 
established  which  are  favorable  for  the  spontaneous  healing  of  any  suppurat- 
ing surfaces  which  may  exist  in  this  tube.  AYe  have  never  injected  Beck's 
bismuth  paste  directly  into  the  Eustachian  tube,  but  it  is  claimed  that  this  is  a 
safe  and  beneficial  procedure  in  these  cases. 

INFECTIVE  SINUS  THROMBOSIS 

This  condition  is  usually  secondary  to  infection  about  the  ear,  scalp,  nose, 
throat,  or  orbit;  the  vast  majority  of  cases,  however,  occur  as  a  complication 
of  middle-ear  disease. 

The  symptoms  are  those  of  septicemia  or  pyemia,  with  frequent  chills  and 
a  very  irregular  temperature,  ranging  from  100°  to  105°. 

The  lateral  sinus  is  the  one  most  frequently  involved.  The  history  is  usu- 
ally one  of  a  middle-ear  infection,  followed  by  chills,  irregular  high  tempera- 
ture, with  pain,  tenderness  and  edema  along  the  line  of  the  sinus  and  down 
over  the  mastoid  and  along  the  jugular  vein,  if  it  is  involved. 

In  thrombosis  of  the  cavernous  sinus  exophthalmus  develops,  together  with 
edema  about  the  orbit  and  eyelids.  Choked  disc  is  also  present  and  there  is 
apt  to  be  paralysis  of  the  third,  fourth  and  ophthalmic  division  of  the  fifth 
and  sixth  cranial  nerves. 

Treatment.  In  thrombosis  due  to  middle-ear  disease,  the  mastoid  should 
be  trephined  as  previously  described,  and  the  lateral  sinus  exposed  and  ex- 
amined to  determine  the  presence  of  a  thrombus.  The  jugular  vein  shiuld 
then  be  ligated  to  prevent  further  dissemination  of  the  thrombus  downwards. 
The  lateral  sinus  is  now  opened,  and  if  the  thrombus  has  extended  down  into 
the  jugular  vein,  the  portion  of  the  vein  above  the  ligature  should  be  excised. 
The  sinus  can  now  be  irrigated  through  into  the  neck,  after  which  both  ends 
should  be  tamponed  with  gauze.  The  prognosis  is  bad,  the  mortality  being 
at  least  fifty  per  cent. 

REMOVAL  OF  THE  GASSERIAN  GANGLION 

During  the  past  few  years  this  operation  has  been  performed  many  times 
by  many  surgeons,  so  that  it  is  now  a  thoroughly  established  procedure. 
Gushing  and  Frazier  and  Krause  have  disctissed  the  special  methods  which 
they  have  applied  in  a  very  large  number  during  this  time,  and  for  those  who 
are  particularly  interested  in  this  operation  it  is  well  to  read  the  writings 
of  these  authors. 

Before  performing  this  operation  it  is  most  important  to  do  it  upon  the 
cadaver,  remembering  well,  however,  that  the  chief  difficulty  in  the  operation 
upon  the  living  subject  comes  from  the  fact  that  there  is  always  a  certain 
amount  of  blood  present  to  obscure  the  field,  and  that  for  this  reason  the 
simple  directions  which  follow  are  often  quite  difficult  to  carry  out. 

Operative  precautions  and  technique.  Preparatory  to  this  operation,  pro- 
vision should  be  made  against  the  occurrence  of  an  injury  to  the  conjunctiva, 
from  the  fact  that  the  operation  is  accompanied  by  paralysis  of  this  portion 


120 


SURGERY  OF  THE  HEAD 


which  prevents  the  eyelids  from  protecting  the  conjunctiva  against  injury. 
The  conjunctiva  is  therefore  protected  temporarily  by  closing  the  eyelids  by 
the  application  of  a  few  fine  silk  sutures.  These  are  removed  at  the  end  of 
from  one  to  two  weeks,  and  then  the  eye  is  protected  mechanically  by  the  use 
of  a  properly  adjusted  shield.  The  next  step  consists  in  providing  for  a  blood- 
less operation.  This  can  be  accomplished  by  exposing  the  common  carotid 
artery  and  applying  to  it  a  properly  constructed  clamp,  which  will  close  the 


Temporary  Eesection  of  the  Skull. 

The  elliptical  flap  of  bone  a  remains  attached  to  the  flap  of  the  skin,  fascia,  muscle  and 
periosteum  /.  The  latter  is  represented  somewhat  too  large  in  proportion  to  the  size  of  the 
bone  flap,  h  shows  the  middle  meningeal  artery  with  its  anterior  and  posterior  branches  e 
and  d.  The  chisel  c  is  in  the  position  in  which  it  was  held  for  the  purpose  of  severing  the 
lower  attachment  of  the  bone  flap  after  the  horseshoe  shaped  groove  had  been  cut  vnth  the 
De  Vilbiss  forceps.  The  entire  flap  should  be  placed  a  little  higher  for  the  purpose  of  ligating 
the  branches  of  the  middle  meningeal  artery  and  somewhat  lower  for  the  removal  of  the 
Gasserian  ganglion. 


lumen  of  this  vessel  without  crushing  the  intima.  The  pressure  should  be 
carefully  graded,  so  that  this  object  may  be  accomplished  with  certainty. 
This,  however,  is  possible  only  in  patients  in  whom  arterio-sclerosis  does  not 
exist  to  a  marked  degree.  The  hemorrhage  comes  partly  from  the  middle 
meningeal  artery  and  partly  from  the  dura,  and  both  of  these  sources  are 
of  course  controlled  by  this  temporary  closure  of  the  common  carotid. 


SURGERY  OF  THE  HEAD  121 

A  horeshoe-shaped  incision  one  and  one-half  inches  in  diameter  is  then 
made,  with  its  convexity  upwards,  its  lower  branches  being  opposite  the  lower 
border  of  the  zygomatic  process,  which  is  temporarily  resected,  the  center  of 
the  flap  corresponding  to  a  point  opposite  the  Gasserian  ganglion.  The  tre- 
phine opening  is  them  made  similar  to  the  one  illustrated  for  the  ligation  of 
the  middle  meningeal  artery,  and  then  by  means  of  the  DeVilbiss  forceps  a 
groove  is  cut  in  the  bone  similar  in  shape  to  the  skin-flap,  only  slightly  smaller. 
The  base  of  this  flap  is  severed  by  means  of  a  few  strokes  of  the  chisel,  and 
then  it  is  elevated  and  laid  downwards,  exposing  the  dura.  The  portion  of 
the  zygomatic  process  which  has  been  temporarily  resected  is  carried  down 
with  this  flap  and  increases  the  space  very  considerably.  It  is  best  to  ligate 
the  middle  meningeal  artery  at  once,  because  this  can  be  done  more  con- 
veniently before  the  tissues  have  been  disturbed  by  the  remaining  steps  of 
the  operation.  The  dura  is  now  carefully  separated  to  the  foramen  ovale, 
then  it  is  elevated  between  the  foramen  ovale  and  the  foramen  rotundum  by 
means  of  a  blunt  instrument.  The  three  branches  and  the  root  of  the  Gas- 
serian ganglion  are  then  elevated,  care  being  taken  not  to  approach  the  inner 
side  of  the  Gasserian  ganglion  until  the  remaining  portion  of  the  isolation 
has  been  completed,  because  of  the  danger  of  injuring  the  cavernous  sinus 
and  thus  clouding  the  field  of  operation  for  the  remaining  steps. 

The  second  and  third  branches  of  the  nerve  are  then  severed  and  the 
Gasserian  ganglion  grasped  by  means  of  forceps  and  forcibly  loosened  from 
its  attachment.  In  case  there  is  still  a  considerable  amount  of  oozing,  a  warm, 
moist  gauze  tampon  is  applied  and  left  in  place  undisturbed  for  at  least  five 
minutes.  It  is  then  slowly  removed  and  the  clamp  upon  the  carotid  artery 
is  slowly  loosened.  If  hemorrhage  occurs,  which  is  not  likely  unless  the  middle 
meningeal  artery  has  not  been  properly  ligated,  the  clamp  is  again  tightened 
carefully  until  the  flow  ceases  and  the  bleeding  points  are  caught  and  ligated 
with  fine  catgut,  if  this  is  possible,  otherwise  a  small  iodoform  gauze  tampon 
is  applied  and  held  in  place.  This,  however,  is  not  often  necessary.  The  flap 
is  then  replaced  and  the  skin  sutured,  care  being  taken  to  pass  the  stitches 
entirely  through  the  scalp  in  order  to  stop  bleeding  from  the  scalp  wound 
after  the  clamp  is  loosened.  No  attention  is  paid  to  the  resected  zygomatic 
process  unless  it  refuses  to  stay  approximately  in  its  right  position.  In  that 
case  it  is  held  in  place  by  a  few  catgut  sutures.  During  this  portion  of  the 
operation  the  patient  is  permitted  to  awaken  and  is  placed  in  the  vertical 
position.  The  dressings  are  applied  and  carefully  bandaged.  It  is  well  to 
place  a  light  gauze  pad  over  each  eye  and  to  apply  a  loose  bandage  over  this, 
because  in  this  way  the  eye  on  the  normal  side  will  remain  quiet,  and,  wdth  its 
fellow,  will  remain  undisturbed.  If  the  normal  eye  is  left  open,  the  other  eye 
will  be  compelled  to  move  with  every  motion  of  the  normal  eye,  and  conse- 
quently it  will  be  likely  to  be  disturbed  unnecessarily. 

This  operation  in  the  hands  of  all  operators  together  has  given  a  consider- 
able mortality,  probably  exceeding  twenty  per  cent.,  while  with  a  few  surgeons 
who  have  carefully  developed  a  technique  the  mortality  has  been  exceed- 
ingly small. 

We  have  found  it  advantageous  to  administer  one-fourth  of  a  grain  of 
morphia  hypodermically  to  these  patients  half  an  hour  before  beginning  the 
administration  of  the  anesthetic,  then  to  anesthetize  with  ether  by  the  drop 
method  until  the  patient  is  very  thoroughly  unconscious,  and  then  to  stop 
the  further  administration  of  the  anesthetic  just  before  beginning  the  opera- 
tion, the  patient's  head  being  elevated  by  placing  the  table  in  the  inverted 
Trendelenburg  position.  The  anemia  of  the  brain  caused  by  this  procedure 
serves  to  keep  the  patient  unconscious  until  the  operation  has  been  completed 
and  reduces  the  amount  of  bleeding  to  a  marked  extent. 


122  SURGERY  OF  THE  HEAD 

It  may  be  well  to  caution  the  surgeon  against  the  careless  use  of  the  re- 
tractor in  lifting  the  cerebrum.  A  spartula-shaped  retractor  is  usually  held 
by  an  assistant  for  this  purpose,  and  unless  he  has  been  very  carefully  cau- 
tioned there  is  danger  of  his  traumatizing  the  brain  tissue  during  the  perform- 
ance of  the  operation.  This  part  of  the  work  should  be  given  to  a  thoroughly 
competent  assistant. 

Shock  due  to  avoidable  traumatism  is  undoubtedly  the  cause  of  more 
deaths  during  or  following  this  operation  than  any  other  one  condition,  which 
accounts  for  the  difference  in  mortality  at  the  hands  of  otherwise  equally 
competent  surgeons. 

RESECTION  OF  PORTIONS  OF  THE  FACIAL  NERVE  FOR  THE 
RELIEF  OF  NEURALGIA 

During  the  early  portion  of  an  attack  of  trifacial  neuralgia  usually  only 
one  of  the  principal  branches  is  involved.  The  most  common  one,  in  our 
experience,  has  been  the  submaxillary  branch. 

Internal  treatment  and  dietary.  In  all  cases  of  trifacial  neuralgia,  with- 
out regard  to  the  portion  of  the  nerve  involved,  it  is  wise  always  to  subject 
the  patient  first  to  carefully  directed  internal  treatment.  In  a  considerable 
proportion  of  these  cases  the  affection  seems  to  be  due  to  an  auto-toxemia 
from  the  alimentary  tract.  In  these  cases  the  daily  use  of  from  two  to  four 
ounces  of  castor  oil,  given  in  the  foam  of  beer,  will  result  in  a  permanent 
cure  in  at  least  one-half  of  all  instances.  At  first  the  oil  will  act  as  a  violent 
cathartic,  but  this  property  soon  disappears,  and  after  a  few  weeks  the  patient 
may  continue  to  take  this  amount  of  castor  oil  daily  without  any  disturbance 
of  the  bowels. 

In  the  meantime  these  patients  should  be  cautioned  against  the  use  of 
food  which  is  likely  to  cause  undue  fermentation.  Sugar  should  be  pro- 
hibited entirely.  Starchy  foods  should  be  limited,  and  acids  used  very  spar- 
ingly. In  case  this  and  other  forms  of  treatment  fail  to  give  relief,  the  ex- 
cision of  a  portion  of  the  affected  nerve  is  indicated.  During  the  past  few 
years  a  number  of  surgeons  have  advised  the  excision  of  the  Gasserian  gan- 
glion for  the  relief  of  all  facial  neuralgias  without  regard  to  the  branch  in- 
volved. This  seems,  however,  scarcely  justifiable,  because  in  many  cases  in 
which  only  a  portion  of  the  affected  branch  has  been  excised  the  patient  has 
recovered  completely  and  permanently ;  and  if  a  complete  recovery  does  not 
occur,  it  is  still  possible  to  perform  a  radical  operation. 

Injection  of  alcohol.  During  the  past  few  years  we  have  obtained  excel- 
lent results  in  many  cases  by  injecting  1  per  cent,  cocain  in  85  per  cent,  alcohol 
directly  into  the  nerve  sheath,  or  as  near  the  nerve  as  possible.  This  should 
be  repeated  once  a  week  until  the  pain  ceases  to  return.  Sometimes  one  in- 
jection will  suffice,  but  more  frequently  it  is  necessary  to  repeat  several  times. 
It  may  be  necessary  to  inject  as  often  as  five  or  even  ten  times.  In  cases 
relieved  b}^  this  method  one  can  usually  count  on  freedom  from  pain  for  at 
least  one  year,  when  the  treatment  may  be  repeated  sometimes  Avith  equally 
satisfactory  results. 

In  the  meantime  the  patient  should  be  under  strict  supervision  regarding 
the  state  of  his  general  health.  His  diet  and  hygiene  should  be  carefully  con- 
trolled. The  food  should  be  consistently  chosen,  thoroughly  masticated,  and 
absorption  of  products  of  decomposition  from  the  contents  of  the  alimentary 
canal  should  be  prevented.  The  urine  should  be  examined  at  regular  inter- 
vals, especially  for  the  presence  of  indican. 

The  condition  of  the  patient's  teeth  should  be  made  as  nearly  perfect  as 


SUEGERY  OF  THE  HEAD  123 

possible,  and  all  other  influences  affecting  liis  general  health  should  be  care- 
fully controlled. 

Technique.  In  order  to  succeed  it  is  well  to  have  a  human  skull  at  hand 
at  the  time  of  operation,  inasmuch  as  this  gives  the  operator  a  better  idea  of 
distance  and  direction  than  he  can  have  otherwise. 

It  is  also  advisable  to  inject  methyl-blue  experimentalh^  in  the  cadaver 
in  order  to  gain  accuracy  in  actually  reaching  the  nerve. 

Especial  needles  10  cm.  long,  1  mm.  or  1%  mm.  in  diameter,  containing 
a  stylet,  can  be  obtained  from  the  instrument  makers,  to  be  used  in  this 
operation,  but  different  surgeons  prefer  needles  of  different  thickness  and 
style,  the  important  point  being  to  secure  a  needle  that  will  penetrate  the 
deep  tissues  in  the  exact  direction  intended  by  the  operator.  If  the  injection 
fails  to  give  relief,  and  if  the  area  supplied  by  the  branch  injected  is  not 
analgesic  after  the  mixture  has  been  forced  into  the  tissues,  it  is  certain 
the  nerve  has  not  been  reached.  In  this  event  it  is  best  to  force  the  needle 
in  a  little  farther  and  to  inject  2  cc.  more  of  the  fluid.  If  this  again  fails, 
the  needle  should  be  withdrawn  slightly,  and  more  of  the  fluid  should  be  in- 
jected at  various  points.  If  this,  in  turn,  is  ineffectual,  it  is  best  to  withdraw 
the  needle  and  to  bear  in  mind  the  direction  of  its  employment  and  then  to 
repeat  the  injection  in  a  slightly  different  direction  after  a  few  days.  It  is 
not  wise  to  risk  tearing  the  tissues  by  pushing  the  needle  in  different  direc- 
tions at  one  sitting. 

Injection  of  the  inferior  branch  of  the  fifth  nerve.  The  needle  is  inserted 
at  the  lower  border  of  the  zygoma,  one  inch  in  front  of  its  descending  root, 
which  is  near  the  anterior  long  border  of  the  external  auditory  meatus. 

The  needle  is  directed  a  little  backward  and  slightly  upward,  so  as  to 
hug  the  base  of  the  skull,  and  it  should  reach  the  nerve  at  its  exit  from  the 
foramen  ovale  at  a  depth  of  4  cm. 

The  middle  branch.  Draw  a  line  from  the  posterior  border  of  the  ascend- 
ing process  of  the  malar  bone  to  the  lower  border  of  the  zygoma.  Insert  the 
needle  .5  cm.  posterior  to  this  point,  directed  so  that  it  would  reach  the  fora- 
men rotundum  in  the  skull  you  have  for  comparison.  The  nerve  is  reached 
at  a  depth  of  5  cm. 

The  supraorbital  branch.     Inject  from  the  supraorbital  notch  or  foramen. 

Osmic  acid  injections.  This  method  has  been  almost  entirely  discarded 
since  the  introduction  of  the  injection  of  alcohol.  It  differed  from  the  latter 
in  the  fact  that  the  diseased  nerve  was  laid  bare  at  the  most  available  point 
and  a  few  drops  of  osmic  acid  injected  directly  into  it.  The  results  were  no 
better  than  those  now  secured  from  the  injection  of  alcohol,  and  no  more  per- 
manent, hence  the  latter  method  must  be  preferred  because  of  its  ease  and 
safety  of  application. 

RESECTION  OF  THE  INFERIOR  DENTAL  AND  LINGUAL  NERVES 

In  our  practice  these  two  branches  have  always  suffered  simultaneously,  so 
that  we  have  never  been  forced  to  operate  only  upon  one  or  the  other  singly. 

Both  of  these  nerves  may  be  approached  conveniently  through  an  opening 
in  the  lower  jaw.  An  incision  is  made  along  the  lower  border  of  the  jaw, 
beginning  at  a  point  a  little  behind  the  angle  and  extending  forward  an  inch- 
and-a-half.  This  incision  is  carried  down  to  the  bone.  The  periosteum,  to- 
gether with  the  attachment  of  the  masseter  muscle,  is  then  pushed  upwards 
by  means  of  a  chisel  and  an  opening  one-fourth  of  an  inch  in  diameter  is 
made  exactly  in  the  middle  of  the  ascending  ramus  of  the  jaw  by  means  of  a 
small  trephine  or  a  gouge.  This  will  expose  the  inferior  dental  nerve.  The 
nerve  is  picked  up  with  forceps  and  drawn  out  through  this  opening.     Then 


124  SURGERY  OF  THE  HEAD 

a  pair  of  hemostatic  forceps  is  placed  upon  the  nerve  and  gentle  traction 
made  forwards  and  downwards  to  loosen  it  as  much  as  possible.  A  second 
incision  is  then  made  directly  opposite  the  mental  foramen.  The  mental 
nerve  which  issues  from  this  foramen  is  readily  found.  It  is  picked  up  on 
an  elevator  and  severed.  The  portion  between  the  mental  foramen  and  the 
trephine  opening  is  then  drawn  out  of  this  opening.  Traction  is  made  upon 
this  portion  of  the  nerve  and  as  much  as  can  be  drawn  out  of  the  foramen 
is  cut  oif.  In  such  manner  the  entire  portion  of  the  nerve  within  the  canal 
in  the  lower  jaw  is  removed.  A  small,  blunt  hook  is  then  inserted  through  the 
foramen  and  passed  around  the  lingual  nerve,  which  is  draw^i  out  through  the 
trephine  opening,  caught  with  hemostatic  forceps,  and  as  much  as  can  be 
drawn  out  by  pulling  upwards  and  downwards  repeatedly,  is  withdrawn 
through  the  trephine  opening.  It  is  then  cut  loose  on  the  distal  side  and  the 
nerve  is  again  caught  with  a  pair  of  artery  forceps,  which  are  twisted  slowly, 
so  that  the  nerve  is  rolled  upon  the  forceps  like  rope  upon  a  windlass.  In 
this  way  a  considerable  portion  of  the  nerve  can  usually  be  drawn  out. 

We  believe  that  in  our  early  cases  we  failed  to  remove  a  sufficient  portion 
of  each  nerve,  and  consequently  experienced  recurrence  in  some  cases,  much 
more  frequently  than  we  have  since  performing  this  more  thorough  operation. 

RESECTION  OF  THE  INFRAORBITAL  NERVE 

The  infraorbital  nerve  is  the  most  common  seat  of  trifacial  neuralgia, 
according  to  statistics  found  in  literature,  but  in  our  own  experience  it  has 
been  less  frequent  than  in  the  inferior  maxillarj^  branch. 

The  simplest  method  of  approaching  this  nerve  consists  in  making  an 
incision  along  the  lower  edge  of  the  orbit  three-fourths  of  an  inch  in  length, 
directly  over  the  infraorbital  foramen,  which  can  readily  be  located  by  making 
pressure  along  this  margin  of  the  orbit  and  determining  the  most  painful 
point.  Care  should  be  taken  to  make  this  incision  slowly,  in  order  not  to 
sever  the  infraorbital  artery  at  the  point  at  which  it  issues  from  the  foramen, 
as  this  would  cloud  the  field  of  dissection  with  blood.  The  three  branches — 
the  supramaxillary,  sphenopalatine  and  infraorbital  nerves — usually  do  not 
separate  before  issuing  from  this  foramen,  but  caution  should  be  observed  in 
making  the  dissection,  not  to  overlook  one  or  the  other  of  these  branches 
in  case  division  has  taken  place  before  exit  from  this  foramen. 

When  the  nerve  has  been  laid  bare  it  should  be  picked  up  on  a  dissector. 
(And  we  would  state  here  that  the  most  convenient  instrument  for  dissecting 
out  nerves  which  we  have  encountered  is  the  old-fashioned  dental  excavator, 
which  is  fine  enough  to  serve  properly  and  still  contains  sufficient  strength 
to  be  useful.)  If  the  foramen  is  complete  its  upper  portion  is  chiseled  away, 
transformmg  it  into  a  groove.  The  nerve  is  then  grasped  with  a  pair  of 
hemostatic  forceps  and  drawn  upward,  and  its  branches  are  followed  wdth 
a  dissector  and  successively  cut  away  at  a  distance  of  about  three-fourths 
of  an  inch  from  the  foramen.  Careful  traction,  which  is  frequently  repeated, 
is  then  made  upon  the  nerve  with  the  forceps.  In  this  manner  more  and 
more  of  the  nerve  can  be  withdrawn. 

If  the  neuralgia  has  been  severe  it  is  well  to  chisel  away  the  upper  wall 
of  the  canal  with  a  blunt  raspatorj'^  after  loosening  the  periosteum  overlying 
it.  A  narrow  retractor  is  then  inserted  underneath  the  periosteum  and  while 
traction  is  made  upon  the  nerve  a  narrow  pair  of  scissors  is  inserted  and  the 
nerve  is  cut  off  a  considerable  distance  from  the  infraorbital  margin. 


SURGERY  OF  THE  HEAD  125 

EXCISION  OF  THE  SUPRAORBITAL  NERVE 

The  operation  which  has  just  been  described  is  also  performed  for  the 
relief  of  supraorbital  neuralgia,  with  the  exception  of  making  an  incision 
along  the  supraorbital  margin  after  shaving  away  the  eyebrow.  If  the  incision 
is  made  directly  through  the  middle  of  the  eyebrow,  and  parallel  to  it,  it 
leaves  no  deformity. 

These  three  operations  last  named  are  relatively  simple  and  safe.  They 
give  rise  to  no  deformity,  and  unless  the  antrum  of  Highmore  is  opened  in 
chiseling  open  the  infraorbital  canal  the  wounds  all  heal  rapidly  and  perfectly. 
In  case  any  one  of  these  procedures  has  been  performed  and  there  is  a 
recurrence  of  the  neuralgia  the  undertaking  may  be  repeated  and  a  second 
attempt  may  result  more  favorably.  If,  however,  a  radical  cure  of  the  con- 
dition is  desired,  then  it  is  best  to  excise  the  Gasserian  ganglion. 

HARE-LIP 

Best  time  for  operating  and  preparation.  In  uncomplicated  cases  of  hare- 
lip the  sooner  the  operation  is  performed,  the  better  it  is  for  the  infant.  This 
should  be  done  some  time  during  the  first  ten  days.  In  cases  associated  with 
cleft-palate,  especially  if  this  be  complete,  it  is  better  to  follow  the  method 
devised  by  Brown,  which  consists  of  placing  a  strip  of  zinc  oxide  adhesive 
plaster  across. the  lip  fissure,  making  it  about  the  width  of  the  upper  lip  and 
extending  sufficiently  across  the  cheek  from  each  side  to  give  firm  resistance 
when  tightly  drawn.  The  strap  is  reapplied  daily  until  the  operation  is 
performed. 

The  advantages  of  this  preliminary  treatment  are  that  it  not  only  pre- 
vents an  increase  of  deformity  and  further  distortion  of  the  face  by  unnatural 
muscular  action,  but  it  has  a  tendency  to  correct  the  deformity,  as  in  crjdng 
and  laughing  the  principal  force  of  muscular  action  is  applied  to  the  most 
prominent  anterior  portion  of  the  maxillary  bones,  which  in  double  hare-lip 
and  cleft-palate  is  the  mandibular  process. 

It  also  has  a  decided  effect  in  the  single  cases,  as  in  all  of  them  the 
maxilla  is  more  prominent  on  one  side  than  on  the  other,  and  the  strap 
has  the  tendency  to  depress  the  more  prominent  side  and  to  bring  the  shorter 
side  forward.  Furthermore,  the  infant  becomes  accustomed  to  take  nourish- 
ment with  the  lip  in  a  condition  similar  to  that  after  operation,  and  to  breathe 
through  the  reduced  air  space.  After  the  daily  application  of  the  adhesive 
straps  for  a  period  of  ten  days  or  two  weeks,  the  above  advantages  will  have 
been  gained  and  the  defect  in  the  lip  should  be  closed. 

Technique.  The  steps  of  the  operation  should  be  planned  so  that  after 
closure  of  the  fissure  there  will  be  practically  no  scar  and  as  little  deformity 
of  the  lip  as  possible.  The  freeing  of  the  lip  from  the  cheek  is  one  of  the  most 
important  parts  of  the  operation,  for  unless  this  is  thoroughly  done  it  will 
be  impossible  to  bring  the  edges  of  the  lip  together  without  tension,  which 
is  apt  to  result  in  a  failure  of  union,  or  in  the  production  of  scars  caused  from 
cutting  of  the  tissues  by  the  stitches. 

After  the  lip  has  been  thoroughly  loosened  the  edges  of  the  cleft  in  the 
lip  must  be  prepared  for  suturing.  This  is  accomplished  by  using  a  very 
sharp,  thin-bladed  scalpel,  with  which  a  thin  strip  of  tissue  is  excised  from 
the  border  of  the  lip  on  each  side  of  the  fissure.  The  dissection  is  com- 
menced at  the  upper  border  of  the  lip  and  carried  downwards,  removing 
a  very  thin  layer  of  tissue.  The  mucous  membrane  from  the  lower  one-half 
centimeter  of  the  lip  is  not  excised,  but  is  left  as  a  wedge-shaped  projection 
at  each  comer  of  the  lip.     "WTien  the  lip  is  sutured  these  two  wedge-shaped 


126  SURGERY  OF  THE  HEAD 

corners  are  brought  together  and  form  a  slight  projection  downwards,  which 
will  prevent  the  formation  of  a  notch  as  the  scar  contracts.  This  also  helps 
to  broaden  the  lip. 

If  the  lip  is  too  narrow,  it  may  be  broadened  by  making  a  curved  incision 
in  excising  the  mucous  membrane,  having  the  convexity  of  the  incision  toward 
the  cheek  on  each  side,  thus  removing  only  a  thin  strip  of  mucous  membrane 
at  the  upper  and  lower  corners,  and  a  strip  of  about  one-half  centimeter 
wide  from  the  center  of  the  lip.  As  the  two  concave  surfaces  are  brought 
together  it  will  broaden  the  lip.  In  closing  the  lip  the  sutures  should  be 
placed  with  great  care  and  without  tension.  Two  tension  sutures  of  silkworm 
gut  threaded  in  a  fine  needle  should  be  placed  first.  The  needle  enters  the 
skin  about  one  centimeter  from  the  edge  and  is  carried  in  an  oblique  direction 
and  emerges  from  the  lip  just  at  the  edge  of  the  mucous  membrane  of  the 
posterior  surface  of  the  lip.  It  is  then  passed  into  the  edge  of  the  lip  on 
opposite  side,  entering  at  the  edge  of  the  mucous  membrane  and  emerging 
at  a  point  one  centimeter  from  the  border  on  the  skin  surface.  These  two 
sutures  are  left  untied  until  the  coaptation  sutures  have  been  placed. 

The  mucous  membrane  of  the  lip  is  now  sutured  with  fine  catgut  through- 
out, and  the  edges  of  the  skin  coaptated  by  placing  a  few  horse-hair  stitches. 
The  tension  sutures  are  then  tied,  but  care  should  be  given  not  to  tie  them 
too  tightly.  Adhesive  strips  should  now  be  applied,  so  as  to  take  all  the 
tension  away  from  the  stitches.  The  stitches  should  be  removed  at  the  end 
of  a  week,  but  the  adhesive  strips  should  remain  in  place  for  two  or  three 
weeks. 

DOUBLE  HARE-LIP 

In  cases  in  which  the  prolabium  has  been  left,  it  is  usually  advisable  to 
depress  this  projection  somewhat,  and  then  utilize  it  as  a  central  islanll  in 
the  formation  of  the  new  lip.  The  mucous  membrane  should  be  dissected 
ofi'  of  the  three  borders  of  the  prolabium,  and  from  the  two  borders  of  the 
lip.  An  incision  about  one-half  centimeter  long  should  be  made  in  each  lip 
a  little  below  its  center  and  at  right  angles  to  its  freshened  edge.  The 
upper  half  of  the  lip  is  now  sutured  to  the  lateral  borders  of  the  prolabium, 
and  the  edges  of  the  ''lower"  half  of  lip  are  sutured  to  each  other  in  the  mid 
line  and  above  to  the  lower  border  of  the  prolabium. 

CLEFTPALATE 

If  a  hare-lip  is  associated  with  a  cleft-palate,  the  lip  should  be  repaired 
immediately,  or  some  time  during  the  first  three  weeks  of  life,  and  the  cleft 
in  the  palate  left  until  some  later  time. 

Differing  opinion  as  to  best  time  of  operatinof.  Authorities  are  evenly 
divided  on  the  question  of  time  for  operating  for  closure  of  the  palatine  cleft ; 
many  of  them  recommend  that  the  palate  be  closed  in  infancy,  and  this  done 
before  closure  of  the  hare-lip.  The  advocates  of  the  early  operation  advise 
that  the  palate  should  be  closed  durinor  the  first  three  months  after  birth; 
that  there  is  less  shock  at  this  time  of  life  because  the  child's  nervous  system 
is  not  fully  developed :  that  there  will  be  the  minimum  amount  of  deformity, 
for  they  claim  that  all  of  the  tissues,  both  bony  and  soft,  will  develop  more 
naturally  after  the  cleft  is  closed,  and  that  this  development  Avill  allow  a 
normal  speech  to  follow  when  the  child  reaches  a  speaking  age. 

The  question  of  mortality  in  these  infants  is  an  important  one.  There 
is  no  doubt  but  that  these  little  patients  are  better  able  to  stand  an  operation 
of  this  kind  at  the  age  of  eighteen  months,  than  they  are  during  the  first  few 


SUEGERY  OF  THE  HEAD  127 

months  of  life.  Furthermore,  children  during  their  first  year  are  more  sub- 
ject to  toxemias  than  older  ones,  and  are  apt  to  develop  intestinal  troubles 
following  the  operation,  which  are  likely  to  add  to  the  mortality.  It  is  the 
authors'  custom  to  close  only  the  fissure  in  the  alveolar  process  before  the 
age  of  eighteen  months,  and  to  leave  the  remaining  portion  until  such  time 
as  the  child  makes  an  attempt  at  talking.  We  also  caution  the  parents  of  such 
children  against  encouraging  them  in  these  attempts,  because  our  results  have 
been  more  satisfactory  when  the  operation  was  performed  at  the  age  of 
eighteen  months  or  two  years  than  when  the  repair  was  attempted  in  very 
young  children;  moreover,  the  mortality  in  children  at  this  age  has  been 
practically  nothing,  while  in  those  younger  it  has  been  considerable.  In 
older  children  it  is  difficult  to  secure  perfect  speech  unless  great  pains  are 
taken  in  giving  them  instruction. 

Effect  of  training  upon  speech.  The  following  observation,  however,  has 
convinced  us  that  it  is  possible  to  get  these  children  to  speak  very  nearly 
perfectly  if  a  sufficient  amount  of  care  and  patience  are  employed.  If  children 
should  have  learned  a  given  language  before  the  operation  was  performed 
and  have  later  learned  another  language,  we  have  found  that  the  language 
which  they  learned  later  was  spoken  perfectly,  while  the  defects  noted  in 
the  language  learned  before  the  operation  were  likely  to  persist.  It  is  conse- 
quently plain  that  if  these  children  were  taught  to  relearn  their  language 
that  with  care  they  could  accomplish  a  great  deal.  This  we  have  found 
to  be  true  in  practice  and  we  would  consequently  advise  a  systematic  course 
of  instruction  in  the  formation  of  those  sounds  in  the  utterance  of  which 
the  soft  palate  is  involved.  Some  especially  gifted  teachers  have  succeeded 
in  producing  perfect  results  whenever  the  child  has  possessed  a  sufficient 
amount  of  intelligence  to  appreciate  the  instruction,  and  the  necessary  perse- 
verance to  carry  it  out. 

Technique.  Certain  conditions  are  obviously  necessary  in  order  to  insure 
success  from  any  of  the  various  operations  which  have  been  devised  for 
closure  of  cleft-palate,  namely :  The  naso-pharynx  must  be  in  a  fairly  healthy 
condition;  the  operator  must  prepare  broad  edges  of  the  flaps  to  be  united; 
the  flaps  must  be  sutured  carefully  and  without  tension ;  one  must  traumatize 
the  tissues  as  little  as  possible ;  must  keep  the  parts  as  clean  as  possible  after 
operation,  and  it  is  important  to  keep  the  parts  relatively  quiescent  after 
operation. 

The  success  of  this  operation  depends  largely  upon  the  thoroughness  with 
which  the  flaps  are  loosened,  and  if  the  surgeon  appreciates  the  fact  that 
his  operation  is  not  likely  to  succeed  so  long  as  there  is  any  tension  upon  the 
stitches  which  unite  the  edges  of  the  wound  in  operations  for  the  relief  of 
cleft-palate,  he  has  grasped  the  most  important  principle  in  this  operation. 
The  method  of  the  operation  will  vary  with  the  extent  of  the  cleft.  If  this 
is  only  through  the  soft  palate,  it  is  wise  to  split  the  edge  of  the  cleft 
throughout  its  entire  extent,  beginning  at  the  tip  of  the  uvula  on  one  side, 
extending  this  incision  around  the  entire  cleft  to  the  tip  of  the  uvula  on  the 
other  side.  This  produces  a  broad  surface  for  coaptation.  It  is  necessary  to 
make  use  of  an  exceedingly  sharp  scalpel  in  order  to  accomplish  this  incision 
satisfactorily.  After  this  has  been  accomplished,  a  method  must  be  adopted 
for  loosening  the  flaps  on  either  side  so  thoroughly  that  they  will  come 
together  without  the  slightest  tension.  This  can  be  brought  about  by  making 
two  lateral  incisions  along  the  outer  edge  of  the  palate  and  loosening  the  soft 
tissues  by  means  of  an  elevator,  or  a  small  chisel  may  be  applied  to  the  alveolar 
process  of  the  palate  bone,  and  this  may  be  chiseled  off,  as  shown  in  the 
accompanying  drawing. 


128 


SURGERY  OF  THE  HEAD 


It  matters  little  how  large. an  incision  or  opening  is  made  upon  each  side, 
provided  the  flaps  can  be  sufficiently  freed  so  thai  they  will  come  together 
without  injury.     The  lateral  incisions  will  invariably  heal  spontaneously. 

Involvement  of  hard  palate.  In  case  the  cleft  extends  into  the  hard  palate, 
or  through  the  hard  palate,  the  following  method  has  been  most  satisfactory 
in  our  hands,  although  it  is  more  troublesome  than  some  of  the  other  pro- 
cedures that  have  been  found  equally  useful  by  other  surgeons.    The  incision 


Cleft  Palate  Opebatiox. 

(a)  Shows  sutures  on  mucous  membrane  turned  into  nasal  cavity;  (b)  sutures  on  flap 
turned  into  the  cavity  of  the  mouth;  (c)  the  silkworm  gut  suture  which  holds  together  the 
bone  flaps;  (d)  flap  turned  into  the  nasal  cavity;  (e)  flap  turned  into  cavity  of  mouth;  (f) 
incision  through  hard  palate.  In  order  to  make  the  conditions  clear  the  drawing  was  made  to 
represent  only  the  lower  surface  of  the  upper  jaw  with  the  hard  and  soft  palate. 

is  made  under  the  alveolar  process  on  each  side.  A  broad,  thin  chisel  is 
placed  in  this  incision  and  the  horizontal  portion  of  the  palate  is  chiseled 
away  so  that  there  is  a  perfectly  loose  flap,  consisting  of  mucous  membrane  of 
the  mouth,  the  bone  of  the  palate  and  the  mucous  membrane  of  the  nasal 
cavity  attached  only  in  front  and  behind.  If  one  side  or  the  other  is  attached 
to  the  vomer  this  attachment  is  also  loosened.  If  this  flap  is  made  so  loose 
on  each  side  that  it  can  be  carried  over  to  the  flap  on  the  other  side  without 
the  use  of  any  force,  then  one  may  usually  count  on  a  successful  result. 


SURGERY  OF  THE  HEAD  129 

Hemorrhage.  The  hemorrhage  in  this  operation  is  considerable,  but  it 
can  readily  be  controlled  by  means  of  a  tampon.  The  patient  is  in  the  Tren- 
delenburg position,  with  the  head  projecting  beyond  the  table ;  consequently 
there  is  no  danger  of  the  inspiration  of  blood.  After  these  flaps  have  been 
made  the  fissure  which  has  been  formed  under  the  alveolar  process  should 
be  thoroughly  tamponed  with  iodoform  gauze  and  the  flaps  should  remain 
undisturbed  for  one  or  two  weeks,  the  nose  and  mouth  being  frequently  irri- 
gated each  day  with  normal  salt  solution.  At  the  end  of  this  time  the  flaps 
are  usually  very  vigorous,  and  readily  heal  if  the  edges  are  freshened  in  the 
manner  we  have  just  described  in  connection  with  operation  for  cleft  of  the 
soft  palate. 

Sutures.  The  most  satisfactory  suture  material  in  our  practice  has  been 
horsehair,  because  it  is  slightly  elastic,  stretching  sufficiently  to  prevent  pres- 
sure-necrosis. Of  course,  it  is  necessary  not  to  tie  these  sutures  tightly,  as 
the  same  elasticity  which  would  be  useful  if  these  sutures  are  tied  loosely  would 
then  become  harmful,  for  it  would  increase  the  amount  of  pressure-necrosis 
precisely  after  the  manner  of  an  elastic  ligature.  It  is  well  to  remember  that 
the  fewer  the  number  of  sutures  that  will  suffice  to  secure  perfect  apposition 
the  greater  will  be  the  likelihood  of  union. 

In  order  to  hold  the  bony  portion  of  the  flaps  in  position  it  is  well  to  pass 
around  them  one  or  two  stitches  of  silkworm  gut,  which  should  be  tied  just 
tightly  enough  to  hold  the  tissues  together  and  not  tightly  enough  to  cause 
pressure-necrosis,  because  the  latter  condition  is  likely  to  result  in  a  complete 
severing  of  one  or  both  bony  flaps.  The  fissures  under  the  alveolar  process 
should  again  be  carefully  tamponed  Avith  iodoform  gauze.  If  the  fissure  ex- 
tends through  the  alveolar  process  in  front,  this  should  be  mobilized  on  either 
side  some  distance  back  from  the  fissure  by  means  of  a  chisel  applied  between 
the  teeth,  and  then  the  edges  should  be  united  at  the  point  of  fissure  by 
means  of  a  catgut  suture. 

In  children  who  are  not  old  enough  to  remain  perfectly  quiet  during  the 
removal  of  the  stitches  it  is  best  to  administer  an  anesthetic  when  the  stitches 
are  removed,  for  fear  of  disturbing  the  line  of  union.  If  possible,  the  sutures 
should  be  extracted  on  the  fifth  or  sixth  day,  as  if  they  are  left  longer  they 
sometimes  result  in  sloughing. 

Brown  operation.  Of  late  the  authors  have  done  the  operation  as  devised 
and  practised  by  Dr.  G.  V.  I.  Brown,  and  with  excellent  results. 

The  operation  is  based  upon  the  fact  that  all  of  these  patients  have  a 
high  arch,  which  increases  the  diameter  of  the  mouth,  and  that  by  lowering 
the  roof  of  the  mouth  the  necessary  width  for  closing  the  fissure  is  obtained. 
The  technique  is  as  follows.     A  short  incision  is  made  along  the  margin  of 


the  alveolar  process,  extending  down  through  the  periosteum  of  the  hard 
palate.  A  small,  thin  chisel  is  then  inserted  down  to  the  botom  of  this  in- 
cision and  the  tissues  of  the  roof  of  the  mouth,  together  with  the  periosteum 
of  the  palate  bone,  are  thoroughly  loosened  from  the  edge  of  the  cleft  back 
to  the  alveolar  process.  Both  sides  are  treated  in  the  same  manner.  The 
edges  of  the  palate  tissue  are  noAV  carefully  trimmed  ofi^  in  a  manner  so  as  to 
secure  broad  surfaces  for  coaptation.  A  fine  silver  wire,  with  a  silver  plate 
about  one  centimeter  in  diameter  fastened  to  one  end,  is  now  passed  throuQrh 
the  flap  on  one  side  at  a  point  about  one  centimeter  from  its  inner  margin, 


130  SURGERY  OF  THE  HEAD 

and  then  carried  across  and  brought  up  through  the  opposite  flap  at  a  corre- 
sponding point,  and  left  loose  until  the  coaptation  sutures  have  been  placed. 
The  edges  of  the  two  flaps  are  now  very  carefully  united  by  horse-hair  or  fine 
silk  stitches,  being  very  cautious  not  to  draw  them  tight.  A  silver  plate  about 
a  centimeter  in  diameter  is  now  threaded  upon  the  free  end  of  the  silver  wire, 
and  then  three  or  four  drilled  shot  are  threaded  down  on  top  of  the  plate. 
The  object  of  using  several  of  the  shot  is  to  be  able  to  obtain  the  exact  tension 
desired  on  the  silver  stitch.  The  outermost  one  of  the  shot  is  now  crushed, 
and  then  the  tissues  tested  for  the  desired  tension.  If  the  tension  is  not 
enough  the  other  three  shot  are  pushed  down  a  little  and  the  next  crushed 
onto  the  wire.  As  soon  as  the  desired  tension  is  secured  the  innermost  shot 
is  crushed  and  the  superfluous  wire,  together  with  the  other  three  shot,  are 
removed.  It  is  usually  necessary  to  make  one  or  two  lateral  incisions  through 
the  flaps  along  the  alveolar  process  in  order  to  relieve  any  possible  tension 
that  may  be  present.  The  stitches  should  be  left  in  place  about  seven  to  ten 
days,  cleansing  and  spraying  daily. 

Lane's  operation.  In  some  patients,  where  the  cleft  in  the  palate  is  very 
wide,  the  closure  can  best  be  made  by  Arbuthnot  Lane's  urano-plasty.  The 
operation  consists  in  inverting  inwards  toward  the  median  line  a  flap  com- 
posed of  all  the  soft  tissues  of  the  roof  of  the  mouth,  the  pedicle,  or  hinge,  of 
the  flap  corresponding  to  the  edge  of  the  cleft,  and  suturing  the  edge  of  this 
flap  underneath  a  flap  of  the  soft  tissues  from  the  opposite  side  of  the  palate. 

Technique.  An  incision  is  made  along  the  margin  of  the  alveolar  process 
on  one  side  through  the  muco-periosteum,  and  is  carried  back  into  the  soft 
palate,  going  through  the  mucosa  of  the  soft  palate,  but  not  injuring  its  mus- 
culature. From  the  hard  palate  a  muco-periosteal  flap  is  loosened,  and  from 
the  soft  palate  the  flap  consists  of  mucosa  and  submucosa,  the  dissection  of 
both  being  carried  toward  the  mid-line,  leaving  the  edge  of  the  cleft  as  a 
hinge  for  the  flap.  The  other  flap  is  prepared  by  grasping  the  uvula  and 
soft  palate  with  a  pair  of  forceps  and  pulling  it  forward  to  expose  the  nasal 
side  of  the  soft  palate.  An  incision  through  the  mucosa  is  made  along  the 
posterior  edge  of  the  soft  palate,  where  it  is  carried  forward  along  the  edge 
of  the  hard  palate.  A  mucosa  flap  is  now  reflected  from  the  nasal  side  of  the 
soft  palate,  and  a  muco-periosteal  flap  from  the  hard  palate,  the  same  as  on 
the  opposite  side,  except  the  dissection  is  begun  from  the  mid-line  and  carried 
outwards,  leaving  the  pedicle,  or  base  of  the  flap,  along  the  alveolar  border, 
instead  of  the  inner  margin  of  the  cleft,  as  on  opposite  side. 

The  first  flap  is  now  inverted,  so  that  its  epithelial  surface  is  toward  the 
nose  and  its  raw  surface  toward  the  mouth.  The  edge  of  this  flap  is  now 
tucked  under  the  edge  of  the  second  flap  and  sutured  to  its  under  surface  by 
a  double  row  of  fine  silk  or  horsehair  sutures.  In  this  manner  very  large 
clefts  can  usually  be  closed  without  any  tension,  insuring  primary  healing 
throughout.  The  denuded  surface  left  in  the  roof  of  the  mouth  heals  over 
very  rapidly. 

Fistulae  following  operation.  It  happens  occasionally  that  a  fistula  re- 
mains in  some  portion  of  a  wound  which  has  been  sutured.  This  may  be  due 
to  the  cutting  of  a  stitch,  or  there  may  have  been  a  certain  amount  of  tension 
which  prevented  union,  or  there  may  have  been  a  slight  amount  of  infection. 
If  these  fistulffi  are  painted  every  day  with  tincture  of  cantharides  they  are 
likely  to  unite  very  rapidly.  If  it  fails  to  unite  after  this  treatment  has 
been  tried  for  several  weeks  it  is  best  to  leave  the  fistula  for  a  number  of 
months  until  the  surrounding  tissues  have  become  quite  normal,  and  then  to 
make  a  longitudinal  incision  on  each  side  of  it  and  to  loosen  enough  of  the 
soft  tissue  to  permit  the  two  sides  to  come  together  in  mid-line  without  any 


SURGERY  OF  TPIE  HEAD  131 

tension.  These  incisions  should  be  long  enough  to  make  the  flaps  perfectly 
free.  Then  the  fistula  is  freshened  and  united  by  means  of  a  stitch.  Occa- 
sionally it  seems  better  to  make  a  horseshoe-shaped  incision  around  one  or 
the  other  end  of  the  fistula  and  thus  to  loosen  a  one-sided  flap  which  will  heal 
directly  over  the  opening. 

EMPYEMA  OF  THE  ANTRUM  OF  HIGHMORE 

For  the  relief  of  empyema  of  the  antrum  of  Highmore  the  most  con- 
venient and  satisfactory  point  of  approach  is  through  the  canine  fossa.  A 
longitudinal  incision  is  made  parallel  with  the  alveolus  of  the  upper  jaw, 
two  centimeters  in  length,  at  the  point  at  which  the  mucous  membrane  ex- 
tends from  the  jaw  to  the  cheek.  The  periosteum  is  elevated  for  a  distance 
of  two  centimeters  and  is  held  out  of  the  way  by  means  of  retractors.  Then 
an  opening  one  and  one-half  centimeters  in  diameter  is  made  by  means  of  a 
gouge,  the  ordinary  carpenter's  chisel  and  mallet  again  being  used.  The 
cavity  is  then  carefully  curetted,  first  with  a  large  and  then  with  a  small 
curette ;  then  it  is  repeatedly  sponged  out  with  a  dry  gauze  sponge,  which 
will  remove  any  granulations  or  remnants  of  polypi.  Then  the  entire  cavity 
is  sponged  with  a  piece  of  gauze  slightly  moistened  with  ninety-five  per  cent, 
carbolic  acid,  or,  better  still,  the  entire  cavity  is  tamponed  full  of  a  strip  of 
gauze  moistened  in  this  manner.  This  tamponing  is  repeated  a  number  of 
tiqnes,  so  that  all  the  lining  of  the  cavity  of  the  antrum  has  been  kept  in 
contact  with  the  strong  carbolic  acid  for  a  period  of  about  five  minutes.  Then 
it  is  tamponed  several  times  with  a  strip  of  gauze  saturated  with  strong  com- 
mercial alcohol  in  order  to  wash  away  any  superfluous  carbolic  acid.  After 
this  the  cavit}^  is  tamponed  with  iodoform  gauze  saturated  with  tincture  of 
benzoin.  This  may  be  left  in  place  for  a  number  of  days,  the  antiseptic  quali- 
ties of  benzoin  being  sufficient  to  prevent  the  cavity  from  becoming  foul. 
After  this  has  been  removed  it  is  usually  sufficient  to  insert  a  small,  self -retain- 
ing rubber  canula  through  which  the  antrum  may  be  irrigated  daily  with 
some  mild  antiseptic  fluid.  If  the  infection  of  the  antrum  has  not  been  of 
long  standing  it  is  not  necessary  to  make  so  radical  an  operation,  the  simple 
opening,  irrigation  and  drainage  of  the  cavity  often  sufficing. 

In  old  cases  it  is  well  to  remove  the  separating  bony  wall  into  the  nose 
for  permanent  drainage  and  for  the  purpose  of  obtaining  an  easily  accessible 
opening  through  which  the  cavity  may  be  cleansed. 

Beck's  bismuth  paste.  Since  the  introduction  of  Beck's  bismuth  paste  we 
have  had  excellent  results  in  the  after-treatment  of  these  cases  by  tamponing 
the  cavity  with  gauze  filled  with  this  paste,  once  in  two  or  three  days,  and 
later  by  injecting  the  paste  through  the  artificial  opening  and  then  closing 
this  opening  with  a  small  gauze  tampon.  This  treatment  is  repeated  daily  at 
first  and  less  and  less  frequently  later  on. 

Mild  cases  will  recover  if  the  antrum  is  filled  in  the  same  manner  with 
Beck's  bismuth  paste  through  a  canula  introduced  through  the  nose,  without 
making  an  artificial  opening  into  the  antrum,  the  nostril  being  tamponed  with 
gauze  after  filling  the  antrum. 

Except  in  cases  of  very  long  standing  it  is  advisable  to  try  this  method 
first,  for  a  few  weeks,  instead  of  at  once  choosing  the  operative  treatment. 
In  case  the  antrum  contains  neither  polypi  nor  necrosed  bone  the  suppuration 
decreases  rapidly,  and  then  the  injections  should  be  made  less  frequently.  It 
is  wise,  however,  to  inject  the  bismuth  paste  once  a  week  after  the  condition 
seems  normal. 


132  SURGERY  OF  THE  HEAD 

EMPYEMA  OF  THE  FRONTAL  SINUS 

The  treatment  which  has  just  been  described  for  empyema  of  the  antrum 
of  Highmore  is  equally  applicable  to  this  condition. 

After  thoroughly  disinfecting  the  nose,  a  canula  is  carried  up  into  the 
affected  sinus  and  the  latter  is  filled  with  Beck's  bismuth  paste  under  very 
moderate  pressure,  the  paste  being  heated  to  110°  F.  It  is  important  to  inject 
the  fluid  slowly  and  to  continue  the  injection  for  several  minutes  in  order  to 
fill  every  portion  of  the  cavity.  In  case  it  is  not  possible  to  pass  a  canula  of 
about  2  mm.  diameter  through  the  nose  into  the  frontal  sinus,  a  passage  should 
be  made  with  a  fine  bone  curette,  or,  if  this  is  not  possible,  Avith  a  fine  gouge. 
This  can  be  done  under  local  anesthesia  with  cocaine,  or  general  anesthesia 
with  ether  may  be  employed.  Extreme  care  and  an  accurate  knowledge  of  the 
anatomy  of  this  region  are  required,  as  there  is  danger  of  perforating  the  inner 
table  and  causing  meningitis,  which  is  usually  a  fatal  complication. 

After  the  sinus  has  been  filled  with  the  bismuth  paste  the  nasal  cavity  is 
tamponed  with  gauze  which  has  also  been  saturated  with  the  paste,  which  will 
serve  to  keep  this  cavity  as  nearly  aseptic  as  possible. 

INFECTION  OF  THE  ETHMOID  CELLS 

In  man.y  cases  this  affection  precedes,  accompanies  or  follows  the  condition 
just  discussed.  The  treatment  depends,  as  in  the  two  previous  diseases,  upon 
disinfection  and  drainage,  the  latter  in  most  instances  accomplishing  the  for- 
mer. Recently  operations  upon  these  cells  have  been  undertaken  in  many 
cases,  which  would  undoubtedly  have  recovered  perfectly  and  permanently 
without  the  necessary  defect  following  an  operation,  had  the  patient's  general 
state  of  health  been  more  carefully  directed.  This  is  especially  true  regarding 
habitual  errors  in  respiration  in  many  of  these  patients.  Their  breathing 
is  habitually  so  shallow  that  they  never  either  fairly  fill  or  empty  their  lungs, 
and  consequently  leave  the  mucous  surfaces  constantly  congested.  By  in- 
structing them  to  inhale  to  their  fullest  capacity  and  then  forcibly  blow  out 
the  air  through  a  small  glass  tube  until  their  lungs  are  as  nearly  empty  as 
possible,  doing  this  many  times  a  day,  these  surfaces  clear  up  rapidly,  and  in 
early  cases,  if  this  practice  be  continued,  we  have  seen  many  who  have  re- 
mained permanently  well,  so  far  as  their  ethmoid  cells  were  concerned,  while 
their  general  health  was  vastly  improved.  Of  course,  the  diet  and  habits  of 
work  and  sleep,  as  well  as  the  ventilation  of  living  and  sleeping  rooms,  must 
be  regulated  at  the  same  time. 

Technique.  Under  local  anesthesia  with  two  to  five  per  cent,  cocaine  in- 
jected through  a  fine,  long  needle,  it  is  possible  to  secure  satisfactory  drainage 
by  curetting  aAvay  the  infected  cells  with  a  strong,  fine,  sharp  curette,  or  to 
bite  them  away  with  strong,  sharp,  gnawing  forceps.  A  dry  tampon  is  first 
applied  and  left  in  place  for  at  least  five  minutes,  then  the  space  is  tamponed 
with  gauze  saturated  with  compound  tincture  of  iodine,  and  then  with  gauze 
saturated  with  Beck's  bismuth  paste.  In  obstinate  cases  two  to  ten  per  cent, 
of  nitrate  of  silver  solution  may  be  used  on  the  tampon,  or  10  per  cent,  solution 
of  argyrol. 

It  is  important  to  bear  in  mind  the  relation  between  these  cells  and  the 
meninges,  because  it  has  repeatedly  happened  that  an  inexperienced  operator 
has  caused  a  meningitis  by  carrying  his  manipulations  too  far. 

Frequently  the  infection  of  the  ethmoid  cells  is  due  to  an  infection  caused 
by  the  presence  of  nasal  polypi.  These  may  produce  the  infection  simply 
from  an  extension  of  this  process,  or  the  natural  drainage  may  be  interfered 
with  owing  to  a  blocking  of  the  nasal  space  due  to  the  presence  of  polypi. 


SURGERY  OF  THE  HEAD  133 

NASAL  POLYPI 

Usually  patients  do  not  come  under  the  surgeon's  care  until  nasal  polypi 
have  attained  a  sufficient  size  to  cause  obstruction. 

Under  cocaine  or  novocaine  anesthesia  the  pedicle  of  the  polypus  can 
usually  be  grasped  with  curved  polypus  forceps  passed  through  the  nares  under 
the  guidance  of  the  index  finger  introduced  through  the  mouth.  The  smaller 
polypi  must  be  removed  by  means  of  a  polypus  forceps  through  a  nasal  spec- 
ulum with  illumination  from  a  head-mirror.  Freer 's  instruments  seem  most 
convenient  for  this  purpose.  This  and  the  previous  operation  are  accompanied 
by  severe  hemorrhages  which  vaay  necessitate  performing  the  operation  in 
several  stages,  with  intervals  of  several  days. 

It  is  possible  in  most  cases  to  do  the  operation  at  one  sitting  by  tamponing 
the  surface  with  gauze  and  interrupting  the  operation  temporarily  while  this 
is  being  done,  but  the  effect  of  this  plan  is  often  not  borne  well  by  the  patient. 

POST-NASAL  ADENOIDS 

The  removal  of  these  structures  is  usually  accomplished  at  the  time  of 
some  other  operation,  like  excision  of  tonsils  or  of  tuberculous  lymph  nodes 
of  the  neck. 

The  patient  is  placed  in  Rose's  position  upon  his  back  with  the  head  pro- 
jecting dependently  beyond  the  end  of  the  table,  and  held  firmly  between 
the  hands  of  an  assistant.  Either  general  or  local  anesthesia  may  be  employed. 
The  uvula  is  drawn  forward  with  the  index  finger  of  the  left  hand  and  the 
adenoids  on  the  posterior  wall  are  cut  away  quickly  by  means  of  a  Gottstein 
curette. 

A  small  ordinary  curette  is  then  introduced,  first  through  one  and  then 
through  the  other  nostril,  and  all  of  the  remaining  adenoids  are  curetted 
away  carefully  under  guidance  of  the  left  index  finger.  It  is  important  to 
protect  the  opening  to  the  Eustachian  tube  with  the  end  of  the  index  finger. 

The  entire  surface  is  then  very  vigorously  rubbed  with  the  index  finger 
covered  with  a  few  thicknesses  of  sterile  gauze. 

The  patient's  diet  and  hygiene  are  carefully  controlled  after  the  operation 
and  especial  stress  is  laid  upon  the  practice  of  breathing  exercises. 

CONTRACTED  NARES 

Nares  which  have  been  contracted  because  of  former  injuries  to  the  nose 
should  be  treated  by  forcibly  loosening  the  displaced  bony  structures  and 
then  treating  the  condition  as  one  would  a  fractured  nose  primarily. 

FRACTURE  OF  THE  NOSE 

In  the  treatment  of  this  accident  two  results  must  be  constantly  borne  in 
mind:  1.  The  patient  must  be  able  to  breathe  through  both  nostrils  after 
recovery.    2.    He  must  not  remain  unreasonably  deformed. 

The  first  object  may  be  accomplished  by  applying  suitable  perforated  in- 
tranasal splints  made  of  hard  rubber,  aluminum  or  silver.  The  latter  purpose 
is  fulfilled  by  carefully  regulating  the  support  to  the  external  surface  of  the 
nose  throughout  the  process  of  healing  by  applying  pressure  pads  at  the  neces- 
sary points.  It  requires  much  ingenuity  to  improvise  means  and  methods 
suitable  for  the  individual  case. 


134  SURGERY  OF  THE  HEAD 

DEFLECTED  SEPTUM 

In  occasional  cases  what  has  just  been  said  applies  with  equal  force  to 
this  condition.  By  grasping  the  detiected  septum  with  strong  forceps  and 
thoroughly  fracturing  it,  so  that  it  ceases  to  take  upon  itself  its  former  de- 
formity, and  then  applying  the  same  intranasal  splints  for  a  month,  excellent 
cosmetic  and  functional  results  may  be  looked  for. 

In  the  majority  of  cases,  however,  the  best  results  are  obtained  by  making 
a  submucous  resection  of  the  septum,  or  a  portion  of  it.  This  is  easil}^  accom- 
plished under  local  anesthesia.  A  four  per  cent,  solution  of  cocaine  is  applied 
to  the  mucous  membrane  over  the  septum  and  then  some  one-half  per  cent, 
novocain  solution  is  injected  underneath  the  mucous  membrane,  between  that 
and  the  cartilage.  This  not  only  makes  the  anesthesia  more  complete  but 
facilitates  the  separation  of  the  mucous  membrane  from  the  cartilage.  An 
incision  is  now  made  along  the  junction  of  the  mucous  membrane  of  the  sep- 
tum with  the  skin,  and  then  by  means  of  a  small,  thin  elevator  the  mucous 
membrane  is  readily  separated  clear  back  to  the  bony  septum.  An  incision 
through  the  cartilage  is  now  made  along  its  anterior  border,  being  careful 
not  to  cut  through  the  mucous  membrane  on  the  opposite  side.  The  mucous 
membrane  can  now  be  readily  loosened  from  the  other  side  of  the  cartilage. 
A  Ballinger  swivel  septum  knife  is  now  inserted  and  as  much  of  the  septum 
as  desired  is  rapidly  removed.  A  small  tampon  of  gauze  placed  in  the  anterior 
nares  holds  the  flap  of  mucous  membrane  in  place  without  the  application  of 
any  sutures. 

SADDLE-NOSE 

If  this  condition  is  due  to  an  old  fracture  this  should  be  refractured  and 
then  replaced  as  nearlj^  as  possible,  and  then  the  case  should  be  treated  accord- 
ing to  the  method  already  described.  If  it  is  congenital,  then  it  is  sometimes 
best  to  correct  the  deformity  by  the  use  of  paraffin  injections. 

Traumatism  is  the  most  common  cause  of  saddle-nose,  and  next  in  fre- 
quency comes  syphilis,  either  acquired  or  congenital.  It  may  also  result  from 
simple  abscess  of  the  septum.  Any  condition  causing  destruction  of  the  nasal 
septum,  may  result  in  this  deformity,  as  that  removes  the  support  of  the  nasal 
bones  and  cartilages. 

Several  methods  of  correcting  this  deformity  have  been  devised,  such  as 
inserting  plates  of  celluloid,  platinum  or  silver  underneath  the  skin  as  a  sub- 
stitute for  the  natural  bridge  of  the  nose,  but  none  of  these  is  as  satisfactory 
as  the  transplantation  of  a  piece  of  a  rib  or  costal  cartilage  to  replace  the 
contour  of  the  nasal  bones.  In  the  authors'  experience  the  use  of  the  cartilage 
has  proven  the  most  satisfactory  of  the  two. 

TECHNIQUE  OF  TRANSPLANTING  CARTILAGE 

A  small,  transverse  incision  1  cm.  in  length  is  made  across  the  base  of  the 
nose  extending  down  to  the  bone.  Then  by  means  of  a  small,  thin  elevator 
the  skin  and  subcutaneous  tissue  are  carefully  raised  from  the  nasal  bones, 
being  cautious  to  make  the  separation  in  the  mid-line  only,  and  not  loosen 
the  tissues  from  the  side  of  the  nose.  The  dissection  is  carried  far  enough 
toward  the  tip  of  the  nose  so  that  when  the  undermined  tissue  is  elevated  the 
deformity  will  be  entirely  corrected.  An  estimate  is  now  made  as  to  the  size 
of  the  piece  of  cartilage  necessary  to  replace  the  bridge  of  the  nose.  An 
incision  is  now  made  over  the  costal  cartilage  of  the  seventh  or  eighth  ribs,  and 
the  cartilage  removed.    By  means  of  a  sharp  scalpel  the  cartilage  is  cut  into 


SURGERY  OF  THE  HEAD  135 

the  shape  and  size  estimated  necessary  to  correct  the  deformity  when  inserted 
into  the  nose.  The  cartilage  is  now  grasped  with  a  small  pair  of  forceps,  and 
while  the  small  skin  incision  over  the  base  of  the  nose  is  held  open  with  tenac- 
ulum forceps,  the  cartilage  is  slipped  down  underneath  the  soft  tissue  of  the 
nose,  resting  upon  the  nasal  bones  and  the  septum.  The  incision  is  now 
closed  with  one  or  two  horsehair  sutures.  It  is  quite  remarkable  how  nearly 
some  of  these  saddle-noses  can  be  restored  to  normal. 

Use  of  paraffin.  This  method  of  treatment  is  very  simple,  and  there  is  no 
resulting  scar  from  its  use.  It  has  a  further  advantage  in  that  it  causes  very 
little  reaction  of  the  tissues  and  does  not  necessarily  confine  a  patient  to  the 
house,  thus  allowing  him  to  immediately  resume  his  daily  pursuits. 

Although  the  treatment  is  very  simple,  still  there  are  some  dangers  con- 
nected with  the  use  of  the  paraffin.  The  chief  dangers  are  abscess  formation 
and  sloughing  of  the  tissues  from  infection,  also  sloughing  from  pressure- 
necrosis  from  hyper-injection.  A  few  cases  of  embolism  have  been  reported 
immediately  following  injection  for  deformity  of  the  nose. 

Technique.  If  the  patient  is  an  adult  ancl  is  not  particularly  nervous,  the 
paraffin  may  be  injected  without  the  use  of  a  general  anesthetic.  In  such  it  is 
well  to  administer  a  quarter  of  a  grain  of  morphine  hypodermatically  half  an 
hour  before  the  treatment  is  to  be  given.  The  majority  of  patients  prefer  to 
take  a  general  anesthetic,  the  after-effects  of  which  are  very  slight,  because 
the  patient  is  anesthetized  for  only  a  few  moments. 

It  is  very  important  that  absolute  asepsis  be  carried  out  during  the  process 
of  injection,  for  the  slightest  infection  is  apt  to  result  in  abscess  formation 
and  sloughing  of  the  tissues.  A  special  syringe  should  be  used  so  that  the 
paraffin  can  be  forced  out  through  the  needle  after  it  has  hardened,  and  also 
so  the  paraffin  may  be  injected  very  slowly.  The  syringe  should  be  con- 
structed of  metal  and  fitted  with  a  thumb-screw  upon  a  worm  on  the  piston- 
rod,  which  can  be  screwed  into  the  head  of  the  syringe  after  it  has  been  filled 
with  melted  paraffin.  A  good-sized  ring  should  be  firmly  attached  to  the  distal 
end  of  the  piston-rod  so  that  the  piston-rod  vaay  be  turned  easily,  which  will 
gradually  lower  the  piston  and  force  the  paraffin  out  through  the  needle  in 
the  shape  of  a  cylindrical  thread.  The  syringe  as  devised  by  Harman  Smith 
has  proved  very  satisfactory  to  the  authors. 

The  paraffin  should  be  thoroughly  sterilized,  and  is  then  maintained  in  a 
liquid  state  by  keeping  in  a  hot  water  bath  until  used.  The  paraffin  is  now 
poured  into  the  syringe,  and  allowed  to  solidify  before  injection.  The  needle 
on  the  syringe  should  be  about  two  inches  long  and  should  be  inserted  from 
above  downwards ;  that  is,  toward  the  tip  of  the  nose,  so  that  the  injection 
will  be  made  toward  the  tip  of  the  nose  and  not  toward  the  base.  In  the 
few  cases  of  embolism  of  the  central  artery  of  the  retina  immediately  following 
injection  of  paraffin  for  correction  of  nasal  deformity,  each  injection  was 
directed  toward  the  root  of  the  nose  instead  of  toward  the  tip.  The  skin 
over  the  base  of  the  nose,  a  considerable  distance  above  the  depressed  por- 
tion, should  be  grasped  between  the  thumb  and  finger  of  the  left  hand,  and 
the  needle  introduced  through  the  skin  at  this  point,  then  the  needle  is  passed 
downwards  along  underneath  the  skin  to  a  point  near  the  lowest  part  of  the 
depression.  An  assistant  now  grasps  the  nose  at  its  base  just  above  the  de- 
pression to  prevent  the  paraffin  from  backing  up  above  the  depression.  The 
piston-rod  of  the  syringe  is  now  turned  slowly,  and  as  the  paraffin  enters  the 
tissue  it  is  gently  molded  into  the  proper  shape.  Care  must  be  used  not  to 
inject  too  much  paraffin.  When  the  skin  over  the  area  of  injection  becomes 
white  the  injection  should  be  stopped.  If  the  depressed  area  has  not  been 
raised  sufficiently,  it  is  better  to  inject  a  second  or  third  time  than  to  cause 
too  much  tension  by  injection  of  a  large  amount  primarily.     Care  must  also 


136  SURGERY  OF  THE  HEAD 

be  used  to  have  the  paraffin  lodge  in  the  right  place,  otherwise  the  deformity 
may  be  increased.  After  the  injection  the  needle  puncture  is  sealed  with 
collodion,  and  no  further  dressing  applied. 

FOREIGN  BODIES  IN  THE  NOSE 

Ordinarily  it  is  possible  to  remove  foreign  bodies  from  the  nasal  cavity 
without  difficulty  by  the  use  of  forceps,  blunt  curettes  or  wire  loops,  but  if 
they  have  been  in  position  long  enough  to  cause  edema,  necrosis  or  suppura- 
tion it  is  often  difficult  to  accomplish  their  removal. 

This  is  also  the  case  if  the  patient  has  had  foreign  bodies  forced  into  the 
nose  during  explosions,  or  railway,  automobile  or  runaway  accidents. 

We  have  removed  nails,  stones,  and,  in  o^ie  case,  a  piece  of  wood  4xl.5x.5 
cm.  in  diameter  from  the  noses  of  such  patients. 

In  these  cases  general  anesthesia,  followed  by  a  careful  exploration,  is 
necessary.  After  removal  of  the  foreign  body  the  space  should  be  carefully 
tamponed  to  prevent  infection  and  hemorrhage. 

EPISTAXIS 

Following  the  various  operations  in  the  nasal  cavity,  and  sometimes  inde- 
pendently, patients  suffer  from  severe  hemorrhages  from  the  nose,  which  may 
be  almost  uncontrollable.  But  we  have  always  succeeded  in  overcoming  the 
hemorrhage,  even  in  the  most  desperate  cases,  by  taking  a  piece  of  soft  gauze 
24  cm.  long  and  12  cm.  wide,  and  folding  it  upon  itself  so  as  to  make  a  bundle 
12  cm.  long  and  just  thick  enough  to  occlude  the  posterior  nares.  The  width 
must  vary  slightly  with  the  size  of  the  patient,  and  the  length  with  the  quality 
of  the  gauze.  Two  pieces  of  double  silk  are  tied  about  this  gauze  so  as  to 
divide  it  into  three  equal  portions.  A  small  soft-rubber  catheter  is  now  passed 
through  each  nostril  and  guided  out  through  the  mouth,  then  one  piece  of 
the  silk  is  tied  to  each  catheter  and  pulled  forward  through  each  nostril,  the 
gauze  being  guided  into  place  with  the  index  finger.  The  two  strands  of  the 
double  silk  are  then  separated  and  a  pledget  of  cotton  sufficiently  large  to 
close  the  nostril  is  tied  into  this  string  on  each  side,  the  gauze  being  carefully 
adjusted  in  the  posterior  nares  in  the  meantime  so  as  to  occlude  these  com- 
pletely. 

The  nostrils  will  become  filled  with  blood  and  this  will  form  a  plug  which 
will  supply  the  necessary  pressure  to  control  the  hemorrhage.  The  strings 
should  be  tied  over  the  anterior  plugs  in  such  a  manner  that  they  can  be 
readily  untied  in  two  or  three  days  for  the  removal  of  the  plugs.  If  the 
bleeding  vessels  have  not  been  occluded  hemorrhage  will  recur  at  once,  or 
after  a  short  time,  and  then  the  anterior  plugs  will  have  to  be  renewed. 

CHRONIC  RECURRENT  EPISTAXIS 

This  condition  is  usually  due  to  anemia  and  should  be  treated  with  internal 
remedies,  diet  and  hygiene.  In  other  cases  it  is  due  to  an  erosion  of  some 
vessel  in  the  mucous  lining  of  the  nose.  In  such  event  the  bleeding  surface 
should  be  touched  with  the  electric  cautery  under  local  anesthesia. 

FRACTURES  OF  THE  LOWER  JAW 

In  the  treatment  of  fractures  of  the  lower  jaw  the  fragments  may  be  held 
in  position  by  making  use  of  the  upper  jaw  as  a  splint,  by  forming  a  splint 
of  strong  wire  covered  with  fine  rubber  tubing  and  applying  it  along  the 
alveolar  process,  either  to  the  inside  or  outside  of  the  teeth,  or  upon  both 
sides,  and  holding  the  fragments  in  place  by  winding  wire  about  the  splint 
and  the  teeth.    A  grooved  metal  or  hard-rubber  splint  may  be  employed  to 


SURGERY  OF  THE  HEAD  137 

envelop  the  teeth.  Gold  rims  may  be  placed  on  a  number  of  teeth  and  these 
may  be  held  in  position  by  means  of  screws.  A  horseshoe-shaped  splint  may 
be  fitted  externally  to  the  lower  jaw  and  held  in  place  by  means  of  bandages, 
or  it  may  be  adjusted  mechanically  like  the  ingenious  splint  introduced  by 
Matas. 

Two  conditions  must  be  borne  in  mind  which  are  peculiar  to  fractures  of 
this  bone :  First,  the  proximity  to  the  cavity  of  the  mouth  which  always 
contains  pathogenic  micro-organisms ;  second,  the  fact  that  the  fracture  must 
be  so  dressed  that  feeding  of  the  patient  is  possible.  The  mouth  should  be 
frequently  irrigated  with  normal  salt  or  with  boric  acid  solution,  and  pro- 
vision should  be  made  for  passing  a  tube  into  the  pharynx  through  which  the 
patient  may  receive  liquid  nourishment  at  regular  intervals.  Usually  there  is 
a  space  between  the  teeth,  but  if  this  does  not  exist  a  tube  can  be  carried 
around  the  teeth  into  the  pharynx. 

In  a  large  proportion  of  these  cases  there  is  a  communication  between 
the  fracture  and  the  mouth  cavity.  Fortunately  for  the  patient,  infection  of 
these  compound  fractures  seems  less  harmful  than  in  other  bones. 

TUMORS  OF  THE  JAW 

The  most  common  tumor  of  the  jaw  affects  the  alveolar  process.  It 
begins  as  a  hard,  fibrous  mass  near  the  root  of  a  tooth,  called  an  epulis,  and 
progresses  into  the  substance  of  the  jaw,  the  tooth  becoming  loosened,  and  may 
develop  a  growth  of  considerable  size.  Presently  it  advances  along  the  mucous 
membrane  of  the  mouth  and  later  it  may  extend  into  any  of  the  surrounding 
tissues.  During  the  early  part  of  its  development  this  tumor  is  composed  of 
only  fairly-developed  connective  tissue  cells.  As  it  advances  these  become 
more  and  more  embryonic  until  the  growth  has  the  appearance  microscopically 
of  a  spindle-celled  sarcoma.  If  it  is  partly  removed  its  growth  seems  to  be 
greatly  stimulated,  and  if  removed  incompletely  several  times  it  will  progress 
in  the  usual  course  pursued  by  a  sarcoma. 

Technique.  To  make  room,  one  or  two  teeth  should  be  extracted  beyond 
each  end  of  the  growth,  the  entire  alveolus  should  then  be  chiseled  away 
deeply  and  the  soft  tissues  covering  the  jaw  should  be  removed,  together  with 
the  bone.  Then  the  entire  area  should  be  thoroughly  cauterized  either  with 
a  Paquelin  cautery  or  with  a  cautery-iron  of  considerable  size  which  has 
been  heated  to  white  heat  in  a  flame.  The  thorough  destruction  of  the  deep 
tissues  by  means  of  the  cautery  seems  to  be  the  important  part  of  this  opera- 
tion.   If  this  is  done  reasonably  early  these  growths  practically  never  recur. 

In  many  of  these  cases  that  have  come  early  we  have  been  able  to  cut  away 
the  growth,  together  with  the  underlying  periosteum,  with  a  sharp  chisel 
and  then  at  once  produce  a  deep  scar  with  the  actual  cautery  without  being 
compelled  to  remove  even  a  single  tooth.  This  should  always  be  done  under 
general  anesthesia,  because  otherwise  one  is  likely  to  cauterize  too  superfi- 
cially. In  the  presence  of  doubt  one  should,  however,  never  hesitate  to  remove 
one,  or  several,  or  even  all  of  the  teeth.  Thoroughness  means  success  in  this 
operation. 

DENTIGEROUS  CYSTS  OF  THE  JAW 

The  retention  of  the  embryonic  teeth  Mdthin  the  jaw  gives  rise  to  the  for- 
mation of  a  bone  cyst.  It  is  frequently  difficult  to  differentiate  this  from 
sarcoma,  except  through  the  history,  although  the  cyst  wall  usually  yields 
under  pressure  with  the  finger  placed  upon  the  inner  side  of  the  jaw,  giving 
rise  to  a  crackling  sensation.  The  patient  is  frequently  aware  of  the  presence 
of  a  swelling  for  months  or  years  before  the  physician  is  consulted.  Were 
he  suffering  from  a  sarcoma  there  would  be  secondary  involvement  long  be- 


138  SURGERY  OF  THE  HEAD 

fore  this  time.  During  the  early  part  of  the  development  of  a  cyst  of  the 
jaw,  however,  it  is  not  possible  to  make  a  positive  diagnosis.  There  is  always 
an  unerupted  tooth  as  the  cause  of  this  affection,  but  so  few  patients  keep 
an  accurate  record  regarding  the  number  of  teeth  they  have  had  extracted 
that  one  cannot  make  any  reliable  calculations  from  the  number  of  teeth  that 
are  left. 

Technique.  The  jaw  should  be  chiseled  open  either  from  below,  an  incision 
being  made  through  the  skin  and  periosteum  and  the  latter  reflected,  or  from 
the  mouth,  one  or  two  teeth  being  extracted  to  make  room  for  the  operation. 
The  cavity  is  carefully  chiseled  out,  tamponed,  and  permitted  to  heal  by 
granulation.  Usually  some  remnant  of  the  embryonic  tooth  is  found.  The 
prognosis  is  good. 

t^equently  these  cases  come  under  the  care  of  the  surgeon  after  they  have 
been  operated,  showing  only  a  sinus  leading  down  to  the  denuded  bone,  which 
we  have  often  discovered  to  represent  the  lining  of  the  infected  cyst,  but 
more  frequently  we  have  found  a  portion  of  a  tooth  or  a  partly-developed 
tooth  at  the  bottom  of  the  sinus. 

SARCOMA  OF  THE  LOWER  JAW 

The  only  treatment  that  promises  relief  in  sarcoma  of  the  lower  jaw  is  the 
excision  of  the  entire  half  of  the  maxilla  involved.  This  is  accomplished  by 
making  an  incision  along  the  lower  border  of  the  jaw  from  the  angle  thereof 
to  a  point  beyond  the  middle  line  of  the  chin.  The  soft  tissues  are  carefully 
separated,  the  mouth  opened,  a  tooth  is  extracted  opposite  the  point  at  which 
the  jaw  is  to  be  separated,  and  then  a  chain  saw  or  a  wire  saw  is  carried  around 
the  bone,  and  while  the  wound  in  the  skin  is  retracted  in  order  to  prevent  its 
injury,  the  bone  is  sawed  off.  The  end  of  the  jaw  is  then  grasped  in  a  pair  of 
lion-jawed  forceps  and  carried  out  through  the  wound  in  the  skin.  If  the 
tumor  is  located  near  the  angle  of  the  jaw  it  is  best  to  remove  the  entire  half 
of  the  maxilla,  making  an  ex-articulation.  This  is  accomplished  by  succes- 
sively loosening  the  soft  tissues,  grasping  the  bleeding  vessels  that  are  encount- 
ered, and  forcing  the  jaw  outward,  dislocating  the  joint  and  then  cutting  away 
the  capsule.  The  only  point  at  which  one  encounters  any  difficulty  is  the 
attachment  of  the  styloid  process,  but  with  a  little  care  and  manipulation  this 
can  be  loosened  readily. 

It  is  wise  to  grasp  the  facial  artery  and  vein  at  the  point  at  which  they 
cross  the  lower  jaw  before  cutting  these  vessels,  because  in  this  way  the  wound 
may  be  kept  practically  free  from  blood.  A  drain  is  inserted  in  the  posterior 
and  anterior  angles  of  the  wound.  The  mucous  membrane  is  first  sutured  and 
then  the  skin  is  sutured  up  to  the  point  of  drainage. 

In  case  any  of  the  surrounding  tissues  have  become  involved  these  should 
be  removed  freely,  but  it  is  doubtful  whether  much  benefit  can  come  in  these 
cases  from  an  operation  if  the  disease  has  advanced  to  the  point  of  invasion 
of  surrounding  tissues. 

CARCINOMA  OF  THE  LOWER  JAW 

Carcinoma  of  the  epithelial  structures  of  the  mouth  frequently  invades  the 
lower  jaw.  Usually  cases  which  have  advanced  to  this  stage  are  practically 
hopeless,  still  it  is  proper  to  attempt  the  cure  of  some  by  employing  the  treat- 
ment which  has  just  been  described  in  connection  with  sarcoma  of  the  lower 
jaw. 


SUEGERY  OF  THE  HEAD  139 

ALVEOLAR  ABSCESS 

This  affection  is  so  simple  that  it  seems  scarcely  necessary  to  describe  its 
treatment,  which  should  consist  in  thorough  disinfection  of  the  cavity  of  the 
mouth,  free  incision  of  the  abscess,  thoroUigh  irrigation  of  the  mouth  after 
incision  at  intervals  of  one  hour  at  first  and  less  frequently  later.  Should  the 
incision  show  a  tendency  to  close  a  folded  piece  of  rubber  tissue  may  be  inserted 
to  keep  the  wound  open,  and  thus  facilitate  drainage  and  healing  from  the 
bottom. 

OSTEOMYELITIS  OF  THE  LOWER  JAW 

Following  severe  infectious  diseases,  or  severe  infection  from  the  root  of  a 
tooth,  there  is  frequently  a  destruction  of  a  portion  or  the  entire  lower  jaw, 
due  to  osteomyelitis.  Occasionally  this  disease  also  follows  a  compound  frac- 
ture of  the  lower  jaw.  It  is  accompanied  by  severe  pain,  much  edema,  a  high 
temperature  and  frequently  by  severe  chills. 

Technique  in  acute  cases.  When  seen  in  the  acute  stage  a  free  incision 
should  be  made  through  all  the  tissues,  including  the  periosteum  down  to  the 
bone.  This  will  relieve  the  tension  and  produce  drainage  by  directing  the 
lymph  stream  away  from  the  infected  area.  This  will  reduce  the  necrosis  of 
bone  tissue  to  a  minimum.  In  many  instances  almost  no  sequestration  will 
follow,  as  the  bone  seems  to  have  the  power  of  regenerating  Avithout  destruc- 
tion, while  in  cases  in  which  the  periosteum  has  not  been  incised  large  portions 
of  the  bone  will  be  exfoliated  in  the  form  of  sequestra. 

In  later  cases  in  which  the  jaw  bone  has  already  been  destroyed  by  the 
infection  it  is  a  grave  error  to  remove  the  dead  bone  at  once.  In  these  the 
periosteum  should  also  be  laid  open  and  the  dead  maxilla  should  be  left  in 
place  to  act  as  an  irritant  to  the  formation  of  an  involucrum,  and  also  to  take 
the  place  of  a  mold  over  which  the  involucrum  can  be  formed  without  unneces- 
sary and  unsightly  deformity. 

This  treatment  will  be  followed  by  the  formation  of  a  nearly  perfect 
maxilla;  while  neglecting  to  incise  the  periosteum,  or  removing  the  dead  bone 
at  once,  will  be  equally  certain  to  produce  results  which  are  cosmetically  and 
functionally  bad  in  proportion  to  the  extent  of  the  disease. 

Technique  in  chronic  cases.  In  old,  neglected  cases  and  in  those  which 
were  not  treated  surgically  at  all  during  the  acute  stage,  or  treated  too  late,  or 
in  which  the  periosteum  had  been  properly  incised  during  the  acute  stage  and 
in  which  an  involucrum  has  improperly  formed,  the  sequestrum  causes  con- 
tinuous discharge  of  pus  through  one  or  more  fistulce.  In  all  these  the  seques- 
trum should  be  exposed. 

It  is  usually  necessary  to  cut  away  some  of  the  involucrum  here  or  there 
in  order  to  remove  all  of  the  necrosed  bone.  This  should  be  done  carefully  in 
order  not  to  fracture  the  involucrum.  The  space  should  be  temporarily 
tamponed  with  gauze  for  two  or  three  weeks;  the  skin  should  be  carefully 
sutured  in  order  to  reduce  the  deformity  to  a  minimum.  After  the  gauze  has 
been  removed  it  is  well  to  fill  the  space  it  occupied  with  Beck's  bismuth  paste, 
consisting  of  one  part  of  subnitrate  of  bismuth  and  two  parts  of  yellow  vaseline. 
It  is  important  not  to  inject  this  with  much  force,  and  the  injection  should  be 
repeated  once  or  twice  a  week  until  the  cavity  is  closed. 

PHOSPHORUS  POISONING 

In  persons  working  in  badly-ventilated  factories  wherein  phosphorus  is 

employed  in  various  manufactures,  a  necrosis  of  the  jaw  occasionally  occurs. 

The  treatment  must  consist  in  at  once  permanently  changing  the  patient's 


140  SUKGERY  OF  THE  HEAD 

employment,  directing  his  diet  and  his  general  hygiene  and  in  treating  the 
local  condition  the  same  as  acute  osteomyelitis. 

ANKYLOSIS  OF  THE  JAW 

In  complete  ankylosis  of  the  lower  jaw  the  same  operation  is  indicated  as 
in  ankylosis  of  other  joints,  which  is  described  in  another  chapter. 

In  partial  ankylosis  the  jaw  should  be  mobilized  under  ether  anesthesia 
and  cork  posts  should  be  placed  between  the  teeth  on  either  side,  with  the 
mouth  opened  to  the  greatest  possible  degree  in  any  given  case.  The  patient 
should  be  kept  fairly  free  from  pain  by  the  hypodermic  use  of  morphine  for 
at  least  a  Aveek  while  the  mouth  is  being  held  open  in  this  manner.  Then  the 
posts  may  be  removed  and  somewhat  smaller  ones  put  in  their  place  and  worn 
regularly  during  the  night,  while  during  the  daytime  the  patient  may  exercise 
the  jaw.  It  may  be  necessary  to  repeat  the  mobilization  under  anesthesia 
several  times  at  intervals  of  several  weeks. 

The  treatment  should  be  continued  for  a  number  of  months. 

The  mouth  should  be  kept  covered  with  several  layers  of  gauze  while  it  is 
being  held  open  by  the  posts  in  order  to  prevent  harm  from  inspiration  of  dust 
or  cold  air. 

Even  after  the  patient  has  apparently  completely  recovered  it  is  well  to 
wear  the  posts  between  the  teeth  at  least  for  one  night  each  month  to  prevent 
recurrence. 

EXCISION  OF  THE  UPPER  JAW 

The  method  introduced  by  Kocher  seems  most  satisfactory.  AVe  have 
practised  it  in  many  cases.  It  can  be  done  most  easily  by  first  ligating  the 
common  carotid  artery,  temporarily,  or  by  ligating  the  external  carotid  artery, 
either  temporarily  or  permanently.  If  the  temporary  ligation  is  employed  this 
is  removed  after  the  operation  upon  the  jaw  has  been  completed,  the  space 
carefully  tamponed  with  gauze,  and  the  patient  placed  in  the  sitting  posture. 

If  the  operation  is  performed  without  preliminary  ligation  the  patient 
should  have  his  head  elevated  throughout  the  operation  by  using  the  exag- 
gerated inverted  Trendelenburg  position.  A  few  times  we  have  performed 
the  operation  rapidly  in  elderly  persons,  in  whom  preliminary  ligation  seemed 
contra-indicated  because  of  the  presence  of  marked  arterio-sclerosis,  with  the 
patient  in  Rose's  position  with  the  head  dependent  beyond  the  end  of  the 
table,  but  the  plan  of  operating  with  the  head  elevated  seems  much  more 
satisfactory. 

Technique.  An  incision  is  made  in  a  vertical  direction  through  the  middle 
of  the  upper  lip,  it  then  follows  the  base  of  the  nose  up  to  the  edge  of  the  orbit, 
then  outwards  to  the  junction  of  the  malar  and  frontal  bones.  The  entire  flap 
is  reflected  outwards  and  then  the  jaw  is  cut  away  with  heavy  bone-cutting 
forceps.    The  bleeding  is  controlled  by  pressure  with  gauze  pads. 

This  operation  is  indicated  only  for  the  removal  of  malignant  growths, 
hence  it  is  wise  to  apply  large  cautery  irons  heated  to  red-heat  to  all  of  the 
raw  surfaces.  This  will  destroy  any  remaining  portions  of  diseased  tissue 
and  will  definitely  stop  hemorrhage.  The  space  is  then  carefully  tamponed, 
preferably  with  formidine  gauze,  and  the  skin-flap  is  carefully  sutured  in 
place  throughout. 

If  indicated  by  the  condition  of  the  malignant  growth  the  malar  bone  may 
be  removed  in  part  or  entirely.  If  its  orbital  plate  is  removed  it  is  well  to 
remove  the  eye  also. 

The  cosmetic  result  following  this  operation  is  relatively  very  satisfactory. 


SURGERY  OF  THE  HEAD  141 

EXCISION  OF  THE  PAROTID  GLAND 

The  removal  of  a  portion  of  this  gland  is  most  frequently  indicated  in  con- 
nection with  the  removal  of  tuberculous  lymph  glands  of  the  neck.  Its  total 
removal  is  most  commonly  required  for  enchondroma.  It  is  important  in 
these  cases  to  make  a  perfectly  clean  dissection,  because  if  any  portion  of  the 
tumor  remains  it  is  likely  to  recur  in  the  form  of  sarcoma  which  can  only 
rarely  be  permanently  cured  by  a  secondary  operation.  On  the  other  hand, 
if  the  entire  gland,  together  with  its  capsule,  has  been  enucleated  fairly  early 
at  the  primary  operation  a  permanent  cure  may  be  expected.  The  dangers  of 
the  operation  are  unimportant  and  will  be  discussed  in  connection  with  the 
operation  for  the  removal  of  tuberculous  glands  of  the  neck. 

EXCISION  OF  THE  TONGUE 

Carcinoma.  Carcinoma  of  the  tongue  is  not  very  uncommon  and  fortu- 
nately it  is  frequently  amenable  to  surgical  treatment,  the  prognosis  being 
favorable  in  quite  a  considerable  proportion  of  cases.  If  the  portion  involved 
is  confined  to  the  anterior  half  its  removal  is  quite  simple.  The  tongue  is  drawn 
out  of  the  mouth,  is  transfixed  at  its  base  with  a  needle  armed  with  a  strong, 
double-silk  suture ;  the  tongue  is  tied  in  halves,  considerable  force  being  used 
in  order  to  prevent  the  possibility  of  hemorrhage  during  the  operation.  A 
second,  strong,  silk  suture  is  passed  through  the  tongue  just  above  the  insertion 
of  the  first ;  with  this  the  tongue  is  drawn  forward.  Then  the  diseased  portion 
is  cut  away,  leaving  just  enough  beyond  the  silk  ligature  to  permit  the  sutur- 
ing of  the  two  halves  of  the  tongue  in  the  median  line.  Upon  inspecting  this 
surface  the  blood  vessels  on  the  lower  surface  near  the  median  line  can  readily 
be  discovered.  These  are  caught  in  hemostatic  forceps  and  ligated  separately. 
A  row  of  sutures  is  then  applied,  bringing  the  two  halves  of  the  cut  edge  of 
the  tongue  in  accurate  apposition.  These  sutures  are  carefully  tied  and  then 
the  silk  sutures  are  cut.  The  second  silk  suture  which  was  applied  is  left  in 
place  for  twenty-four  or  forty-eight  hours  in  order  to  prevent  the  tongue  from 
falling  back  into  the  pharynx.  This  accident  happens  very  rarely,  but  when  it 
does  occur  it  is  very  troublesome  unless  some  provision  is  made  for  holding  it 
forward. 

Glandular  invasion.  The  submaxillary  lymphatic  glands  and  the  cervical 
glands  in  front  of  the  deep  jugular  vein  are  most  likely  to  be  involved 
secondarily  in  this  condition,  and  if  the  disease  is  at  all  advanced  it  is  wise  to 
make  an  incision  on  each  side  and  remove  these  glands,  even  though  it  may 
not  be  possible  to  palpate  them  through  the  skin.  If  the  disease  extends  to  the 
posterior  portion  of  the  tongue,  either  on  one  or  both  sides,  it  is  best  to  make  a 
temporary  ligation  of  the  external  carotid  artery  before  beginning  the  opera- 
tion. This  may  be  accomplished  most  readily  by  laying  bare  the  artery  at  its 
origin  on  each  side  and  applying  a  pair  of  clamps  which  have  been  especially 
constructed  for  this  purpose.  These  clamps  should  not  be  sufficiently  strong 
to  cause  any  injury  to  the  vessel,  but  just  strong  enough  to  prevent  the  pas- 
sage of  blood  through  it.  The  jaws  of  the  instrument  should  be  covered  with 
rubber  tubing  to  prevent  the  crushing  of  the  vessel  walls.  The  operation  is 
thus  rendered  practically  bloodless  and  can  be  accomplished  with  great  thor- 
oughness. The  larger  vessels  should  be  caught  in  hemostatic  forceps  and 
ligated  separately  and  then  the  stump  which  is  left  should  be  carefully  closed 
by  means  of  a  sufficient  number  of  sutures  to  prevent  oozing.  After  the  entire 
surface  has  been  carefully  covered  the  forceps  are  loosened  first  on  one  side 
and  then  on  the  other.  In  case  hemorrhage  occurs  they  can  be  compressed 
9,gain  and  the  bleeding  controlled  by  the  further  application  of  sutures. 


142 


SURGERY  OF  THE  HEAD 


Complications.    With  this  location  of  the  growth  there  is  still  greater  likeli- 
hood of  invasion  of  the  cervical  and  the  submaxillary  lymphatic  glands,  and 


Excision  of  the  Tongue. 

This  plate  shows  the  base  of  the  tongue  compressed  by  two  strong  silk  ligatures  which 
have  been  applied  by  passing  a  needle  armed  with  a  double  ligature  through  the  center  of  the 
tongue  and  tying  in  halves.  These  ligatures  are  removed  after  the  diseased  portion  of  the 
tongue  has  been  cut  and  the  vessels  at  (aa)  have  been  separately  ligated  and  the  sutures  (bb) 
and   (cc)   have  been  inserted. 

When  the  temporary  ligatures  are  cut  traction  is  made  upon  the  suture  (bb),  which  will 
bring  the  lateral  Hajis  "into  api)Osition.  Then  the  sutures  (cc)  are  tied  and  theil  (bb;  the 
mucous  membrane  is  closed  by  a  continuous  cat-gut  suture. 

in  such  instances  their  removal  is  always  indicated,  although  it  may  not  be 
possible  to  palpate  them  through  the  skin.  In  case  the  floor  of  the  mouth  is 
involved  together  with  the  tongue,  the  same  preliminary  compression  of  the 


SUEGERY  OF  THE  HEAD  143 

external  carotid  should  be  made,  but  in  order  to  make  a  complete  removal 
of  the  tissues  it  is  wise  to  split  the  lip  and  the  lower  jaw  through  the  middle 
down  to  a  point  just  above  the  thjToid  cartilage,  to  insert  retractors  in  each 
segment  of  the  jaw,  and  to  open  the  entire  space  by  careful  continuous  dissec- 
tion. In  this  way  the  entire  floor  of  the  mouth  and  the  base  of  the  tongue  may 
be  perfectly  exposed.  The  larger  blood  vessels  are  caught  and  ligated  suc- 
cessively. 

The  excision  of  the  tongue  is  performed  as  described  above  and  if  there  is 
any  mucous  membrane  left  after  the  entire  growth  has  been  freely  excised 
this  is  utilized  for  the  purpose  of  lining  the  floor  of  the  mouth.  After  this 
operation  the  forceps  upon  the  arteries  should  be  loosened  before  the  jaws  are 
united  in  order  that  all  of  the  hemorrhage  may  be  carefully  controlled.  After 
this  has  been  accomplished  the  two  halves  of  the  jaws  are  united  by  means  of 
chromicized  catgut  sutures.  The  floor  of  the  mouth  is  drained  through  the 
lower  end  of  the  incision  and  the  remaining  portion  of  the  wound  is  carefully 
closed. 

This  method  provides  a  very  perfect  exposure  of  the  field  of  operation,  but 
it  is,  of  course,  very  much  more  severe  than  the  operations  which  have  just 
been  described,  and  we  believe  that  it  is  indicated  only  in  cases  in  which  there 
is  involvement  of  the  floor  of  the  mouth. 

RANULA 

In  operating  for  the  relief  of  ranula  the  object  to  be  attained  is  either  to 
establish  a  new  communication  between  some  portion  of  the  ducts  of  the  sub- 
lingual glands  involved  and  the  cavity  of  the  mouth,  or  the  complete  removal 
of  the  entire  gland.  The  simplest  method  by  which  to  re-establish  a  connec- 
tion between  the  ducts  of  the  gland  and  the  cavity  of  the  mouth  is  through  the 
use  of  a  seton.  By  applying  a  large-sized  silk  suture  transversely  across  the 
ranula  and  tying  this  loosely  so  that  it  does  not  have  a  tendency  to  cut  away 
the  intervening  portion  of  the  mucous  membrane,  one  may  frequenth^  secure 
the  growth  of  epithelial  cells  in  these  openings  through  which  the  silk  suture 
passes  so  that  the  lining  of  the  duct  and  the  cavity  of  the  mouth  become  con- 
tinuous. After  this  has  occurred  at  both  the  point  of  entrance  and  exit  of  the 
suture  a  new  suture  may  be  introduced  through  the  same  openings  and  tied 
more  tightly  so  that  the  intervening  tissue  may  become  absorbed  slowly.  The 
opening  formed  between  the  cavity  of  the  ranula  and  the  mouth  will  thus 
become  continuously  lined  with  mucous  membrane  and  presently  a  permanent 
opening  will  be  established.  This,  however,  will  not  occur  in  every  case  and  it 
may  become  necessary,  later,  to  remove  a  considerable  portion  of  the  tissue 
between  the  cavity  of  the  mouth  and  the  ranula,  to  sponge  this  cavity  dry,  and 
to  cauterize  it  either  with  the  actual  cautery  or  with  strong  carbolic  acid,  fol- 
lowed after  a  few  minutes  with  strong  alcohol,  or  by  the  use  of  some  other 
caustic,  and  then  by  the  application  of  a  tampon  of  iodoform  gauze  to  the 
cavity  thus  formed.  In  a  number  of  cases  none  of  these  methods  will  succeed 
and  then  it  may  become  necessary  to  dissect  out  the  entire  gland  in  order  to 
prevent  recurrence.  Unless  the  ranula  has  been  severely  inflamed  it  is  usually 
possible  to  find  a  line  of  cleavage  and  to  peel  out  the  mass  in  a  manner  very 
similar  to  the  method  described  in  the  removal  of  a  branchial  cyst.  It  is 
necessary  to  drain  this  cavity  because  its  communication  with  the  cavity  of  the 
mouth  is  likely  to  prevent  preliminary  healing. 

SUBLINGUAL  CYSTS 

Occasionally  a  dermoid  cyst  is  found  in  the  region  of  the  hyoid  bone  which 
may  be  mistaken  for  a  ranula.     It  may  sometimes  be  differentiated  from  a 


144  SURGERY  OF  THE  HEAD 

ranula  by  the  presence  within  the  cavity  of  some  epidermal  structures,  such 
as  hair  or  teeth.  The  diagnosis  is  usually  not  made  until  these  structures  are 
encountered  because  of  the  much  greater  frequency  of  the  presence  of  an 
ordinary  ranula. 

It  is,  of  course,  very  evident  that  nothing  but  the  complete  excision  of  this 
growth  will  accomplish  anything  desirable.  There  is  usually  a  line  of  cleavage 
which  can  be  followed  and  the  growth  peeled  out  with  little  difficulty,  unless 
there  has  been  a  chronic  inflammation  causing  extensive  adhesions.  It  is 
necessary  to  take  especial  care  in  dissecting  out  this  growth  at  the  point  of  its 
attachment  to  the  hyoid  bone,  because  it  is  at  this  point  that  one  is  likely  to 
leave  a  small  portion  which  will  give  rise  to  a  recurrence. 

EXCISION  OF  THE  TONSILS 

Complications.  In  this  climate  a  large  proportion  of  children  and  young 
adults  suffer  from  the  presence  of  hypertrophied  tonsils,  very  commonly  com- 
plicated hy  adenoids  in  the  post-nasal  space.  This  condition  is  exceedingly 
harmful,  because  it  prevents  the  patient  from  normally  performing  the  func- 
tions of  respiration.  The  amount  of  air  permitted  to  enter  the  lungs  with  each 
inspiration  is  greatly  reduced  unless  the  mouth  be  kept  open,  and  in  that  ease 
the  patient  suffers  from  the  inhalation  of  impurities  otherwise  removed  from 
the  air  by  its  passage  through  the  nostrils,  and  by  inhaling  air  which  has  not 
been  modified  either  in  temperature  or  moisture. 

In  many  children  there  is  a  marked  contraction  of  the  chest  due  to  this 
condition,  and  althou,gh  the  obstruction  may  later  be  removed  the  lung  capacity 
can  scarcely  be  fully  attained  because  of  the  deformity  which  already  exists. 

Avenues  of  infection.  The  tonsils  and  post-nasal  adenoids  are  also  very 
likely  to  become  infected  with  various  pathogenic  micro-organisms,  the  most 
common  acute  forms  being  those  from  ordinary  pus  microbes,  the  diphtheria 
bacilli,  the  micro-organisms  of  influenza  and  the  pneumonia  diplococcus,  while 
a  large  proportion  of  these  patients  suffer  from  infection  with  tubercle  bacilli. 
In  this  way  the  patient  constantly  carries  about  a  dangerous  septic  focus.  In 
many  of  these  cases  the  infection  from  the  tonsils  and  adenoids  extends  into 
the  Eustachian  tubes  and  gives  rise  to  deafness,  or  it  advances  into  the  middle 
ear  through  the  Eustachian  tube,  producing  suppurative  inflammation  of  this 
cavity,  which  may  further  result  in  an  infection  of  the  mastoid  cells.  It  is  not 
uncommon,  moreover,  for  the  infection  to  become  acutely  intensified,  resulting 
in  tonsillar  abscess  or  an  infection  of  the  deep  tissues  of  the  neck. 

There  is  scarcely  another  circumscribed  area  in  the  body  from  which  so 
many  secondary  infections  proceed  as  from  the  tonsil.  It  is  one  of  the  most 
common  sources  of  cryptogenetic  infection,  and  is  frequently  responsible  for 
acute  osteomyelitis.  So  long  as  this  organ  is  normal  there  can  be  no  doubt  but 
that  its  lymphatic  structure  enables  it  to  destroy  a  great  number  of  pathogenic 
micro-organisms,  but  after  it  has  once  become  diseased  and  filled  with  these 
micro-organisms  their  presence  is  a  menace  to  the  health  of  the  entire  body. 

Technique.  The  indication  for  treatment  is  unquestionably  plain  in  every 
case  in  which  any  of  the  circumstances  that  have  been  mentioned  exist.  The 
portion  of  the  tonsil  which  causes  the  obstruction,  and  which  contains  the 
septic  material,  should  be  removed.  This  may  be  done  very  easily  and  safely 
by  means  of  any  one  of  a  number  of  instruments  which  have  been  especially 
constructed  for  this  purpose,  or  it  can  be  done  by  grasping  the  tonsil  with  a 
pair  of  volsellum  forceps  and  cutting  away  as  much  as  desired  by  means  of 
a  sharp  scalpel  or  by  a  pair  of  sharp,  long-handled  scissors.  It  is  wise  to 
anesthetize  the  mucous  membrane  by  spraying  the  surface  with  a  four  per  cent, 
solution  of  cocaine,  in  order  to  make  the  operation  less  painful.  If  a  tonsillo- 
tome  is  used,  it  should  be  applied  from  below  upward  and  from  behind  forAvard, 


SURGERY  OF  THE  HEAD  145 

Methods  of  hemostasis.  Unless  the  tonsil  is  acutely  inflamed,  in  which  case 
the  operation  should  be  postponed,  there  is  but  slight  danger  from  hemorrhage. 
If  the  organ  is  drawn  too  tightly  into  the  cavity  of  the  pharynx  before  it  is 
cut  off  the  tonsillar  artery  sometimes  bleeds  considerably.  For  the  purpose 
of  controlling  this  hemorrhage  we  have  found  the  following  mixture  most 
useful :  A  teaspoonful  of  acetanilid,  a  tablespoonful  of  alcohol  and  about  two 
ounces  of  water  are  mixed  and  used  as  a  gargle.  This  usually  stops  the  bleed- 
ing almost  instantly.  If  this  does  not  suffice  pressure  made  with  a  sponge  held 
at  the  end  of  a  pair  of  forceps  for  a  period  of  five  minutes  will  usually  be 
efficient.  Should  this  also  fail  it  is  well  to  insert  a  catgut  stitch  about  the  base 
of  the  tonsil  and  to  tie  just  firmly  enough  to  stop  the  hemorrhage.  There  is 
an  instrument  constructed  with  two  padded  branches,  one  of  which  is  inserted 
into  the  mouth  and  placed  directly  upon  the  bleeding  tonsil,  and  the  other  at  a 
point  opposite  on  the  outside  of  the  neck.  "When  this  instrument  is  closed  it 
makes  a  sufficient  amount  of  pressure  on  the  tonsil  to  stop  the  bleeding. 

For  the  after-treatment  the  patient  should  be  given  some  mild  antiseptic 
gargle,  which  should  be  used  mornings  and  evenings  for  a  number  of  months 
following  the  operation,  in  order  to  improve  the  state  of  the  mucous  membrane 
of  the  pharynx. 

The  post-nasal  adenoids.  In  these  cases  it  is  usually  wise  at  the  same  time 
to  curette  away  the  post-nasal  adenoids  by  means  of  a  flat  curette  with  the 
cutting  edge  at  right  angles  to  the  handle  and  directed  away  from  the  handle. 
The  instrument  known  in  the  market  as  the  Gottstein  curette  is  most  useful  for 
this  purpose.  The  first  finger  of  the  left  hand  should  be  inserted  above  the 
uvula,  and  with  the  right  hand  the  adenoids  should  be  curetted  away  with  a 
few  quick  motions.  If  the  patient  is  anesthetized  for  this  purpose  he  should 
be  placed  in  the  inverted  position  with  the  head  dependent  from  the  end  of 
the  table.  After  this  has  been  done  an  ordinar^^  small,  semi-sharp  curette 
should  be  introduced  through  the  nostril,  and  with  the  finger  still  above  the 
uvula  to  guide  the  spoon,  the  slight  remnants  of  the  adenoids  which  have  not 
been  removed  with  the  flat  curette  may  be  carefully  scraped  away.  Then  a 
piece  of  dry  gauze,  doubled  upon  itself  about  two  times,  is  introduced  on  the 
end  of  the  finger,  and  with  this  the  entire  space  is  thoroughly  rubbed,  so  as 
to  remove  any  small  portions  that  may  still  be  present. 

Breathing  exercises.  It  is  important  that  all  patients  who  have  suffered 
from  the  presence  of  h^qDertrophied  tonsils  and  adenoids  should  be  given  care- 
ful instruction  in  breathing  exercises.  They  should  be  taught  to  inhale  fully 
through  the  nose,  with  the  lips  closed,  so  as  to  expand  the  chest  to  its  fullest 
extent,  being  sure  to  make  use  of  the  diaphragm  in  this  exercise.  They  should 
then  force  out  the  air — resisting  with  the  lips — or,  better  still,  they  should 
blow  through  a  small  tube,  with  an  opening  about  two  millimeters  in  diameter, 
until  the  lungs  have  been  emptied  as  much  as  possible.  This  exercise  should 
be  repeated  about  twenty  times  every  morning  and  evening.  It  is  remarkable 
how  greatly  these  patients  are  benefited  by  this  simple  exercise. 

Methods  of  holding  the  patient.  Concerning  the  operation  of  tonsillotomy, 
we  wish  to  emphasize  the  fact  that  it  is  greatly  facilitated  by  having  the 
patient's  head  held  perfectly  firm  between  the  hands  and  against  the  chest  of 
an  assistant,  if  the  patient  is  not  under  the  infiuence  of  an  anesthetic.  It  is  wise 
in  this  case  to  have  the  patient  drop  his  arms  to  his  sides  and  then  wind  an 
ordinary  bed  sheet  around  his  shoulders  several  times,  so  that  he  cannot  inter- 
fere in  the  operation.  An  adult  not  under  the  influence  of  an  anesthetic  should 
be  seated  in  a  firm  chair,  an  assistant  should  stand  behind  him,  place  one  hand 
on  each  side  of  his  head  and  force  the  same  backward  against  his  chest,  so  that 
the  latter  is  held  firmly  on  three  sides.  Children  are  best  held  by  seating  them 
in  the  lap  of  an  assistant,  who  takes  their  limbs  between  his  knees  and  holds 
the  child  in  the  manner  described  for  performing  intubation. 


146  SURGERY  OF  THE  HEAD 

In  using  the  tenaculum  forceps  and  scissors,  or  scalpel,  it  is  necessary  to 
apply  a  gag  between  the  teeth  of  the  patient.  This  is  also  necessary  in  the  use 
of  some  tousillotomes,  while  with  others  it  is  possible  to  operate  without 
because  the  tonsillotome  itself  prevents  the  teeth  from  closing. 

Limits  of  excision.  Much  discussion  has  developed  of  late  as  to  the  extent 
to  which  it  is  proper  to  remove  tonsils.  For  a  time  it  appeared  as  though  only 
the  complete  removal  of  the  gland  could  be  looked  upon  as  a  proper  opera- 
tion, but  at  the  present  time  even  those  who  are  engaged  in  the  special  field  of 
throat  surgery  seem  to  show  signs  of  conversion  to  the  belief  that  the  best 
operation  is  that  which  removes  only  the  diseased  portion  of  the  tonsil  and 
leaves  the  remainder  for  the  future  protection  of  the  patient. 

TUMORS  OF  THE  LIP 

Angioma.  This  is  the  most  common  of  all  tumors  in  the  lips  of  children. 
The  growth  appears  as  a  little  purple  mark  usually  not  larger  than  the  head 
of  a  pin.  This  will  increase  in  size  in  time  until  it  may  involve  the  entire  lip. 
Later,  it  may  extend  over  the  face  so  that  quite  a  portion  thereof  may'  be 
involved.  After  attaining  some  development  this  growth  is  likely  to  vary  in 
size  with  differences  in  the  temperature  of  the  air  in  which  the  patient  exists. 
While  out  of  doors  in  the  cold  it  will  decrease  so  that  it  can  scarceh^  be  noticed, 
but  when  the  patient  is  in  a  warm  room  it  may  increase  so  as  to  be  quite 
troublesome. 

Angioma  of  the  skin  in  this  vicinity,  as  in  every  other,  should  be  removed  at 
once  as  soon  as  the  diagnosis  is  made,  because  its  removal  is  a  very  simple 
matter  in  the  early  part  of  its  development,  while  later  on  it  may  involve  the 
production  of  a  considerable  deformity.  So  long  as  the  growth  is  very  small, 
not  larger,  for  instance,  than  one  or  two  millimeters  in  diameter,  a  simple 
puncture  with  a  needle  heated  to  white  heat,  or  with  the  fine  knife  of  the 
electro-cautery,  or  the  fine  point  of  a  Paquelin  cautery,  will  suffice  to  destroy 
an  angioma  permanently.  If  the  growth  has  developed  to  a  larger  size  it  is 
best  to  excise  it  and  to  suture  the  wound  so  that  the  scar  will  be  in  the  least 
offensive  position. 

Wyeth  method  of  treatment.  Recently  AVyeth  has  introduced  a  new  treat- 
ment which  is  especially  valuable  in  cases  of  nevus  in  which  the  tumor  has 
advanced  so  far  in  its  development  that  its  removal  would  result  in  a  marked 
deformity,  or  in  which  the  operation  would  have  to  be  so  extensive  as  to 
endanger  the  patient's  life.  In  these  cases  a  large  metal  syringe  is  filled  with 
boiling  water,  which  is  injected  directly  into  the  angioma  through  a  hypo- 
dermic needle  about  the  size  of  an  ordinary  darning  needle.  As  soon  as  the 
surface  of, the  tumor  begins  to  look  white  the  injection  is  stopped.  "We  have 
never  injected  more  than  four  ounces  at  one  sitting,  but  in  case  the  tumor  is 
large  we  think  the  amount  might  be  exceeded  with  safety.  Where  the  tumor 
is  large  we  have  found  it  necessary  to  anesthetize  the  patient. 

The  injected  area  becomes  hard  and  somewhat  swollen  directly  after  the 
injection,  but  within  a  week  absorption  begins,  which  continues  for  several 
weeks.  The  procedure  may  have  to  be  repeated  several  times.  It  is  best  to 
wait  until  the  irritation  has  entirely  subsided  after  one  operation,  before  it 
is  repeated. 

Several  times  when  patients  have  come  from  a  distance  we  have  sent  them 
home  with  directions  to  return  after  several  months  for  further  treatment.  In 
some  of  these  cases  the  cure  was  complete  when  they  returned,  making  further 
treatment  unnecessary.  This  experience  has  caused  us  to  lengthen  the  interval 
between  treatments.  The  method  has  great  value  in  a  class  of  cases  in  which 
excision  could  accomplish  little  or  nothing. 


SUEGERY  OF  THE  HEAD 


147 


Epithelioma.  Epithelioma  of  the  lip  occurs  most  commonly  in  the  lower 
lip  in  the  male.  Its  removal  is  indicated  at  the  time  when  it  is  first  noticed. 
The  removal  should  always  be  extensive,  at  least  half  an  inch  of  perfectly 
healthy  tissue  being  excised  in  every  direction.  •  The  incision  should  be  at 
right  angles  to  the  edge  of  the  lip  and  there  should  be  a  transverse  incision 
joining  the  two  verticals.  All  of  these  incisions  should  extend  entirely  through 
the  lip.  The  transverse  cut  should  extend  beyond  the  vertical  to  about  one- 
fourth  the  distance  between  the  two  vertical  incisions,  so  that  there  is  a  flap 
on  each  side  which  can  be  brought  to  meet  its  fellow  and  then  the  transverse 
incision  can  be  sutured  to  the  lower  edge  of  these  flaps.  A  very  considerable 
amount  of  the  lip  may  be  removed  in  this  manner  without  leaving  any 
deformity  to  speak  of.  If  the  entire  lower  lip  is  to  be  removed  the  defect 
should  be  closed  by  means  of  a  plastic  operation. 

In  epithelioma  of  the  lip  the  submaxillary  lympathic  glands  and  the  cervical 
glands  lying  anteriorly  to  the  sterno-cleido-mastoid  muscle,  and  externally  to 
the  deep  jugular  vein,  are  the  ones  which  are  most  likely  to  be  involved.  If 
the  epithelioma  is  at  all  advanced  these  glands  should  always  be  exposed  and 
removed. 

Of  late  we  have  subjected  all  of  these  patients  to  prophylactic  X-ray  treat- 
ment after  the  operation.  AYhether  this  will  prove  a  proper  course  to  pursue 
must  be  determined  by  further  experience. 

"With  a  thorough  operation  performed  reasonably  early  the  prognosis  is 
very  good. 

EPITHELIOMA  OF  THE  FACE 

What  has  been  said  regarding  epithelioma  of  the  lip  applies  to  epithelioma 
of  any  portion  of  the  face.    The  excision  should  be  done  as  early  as  possible. 


I 


Prickle  Cell  Epithelioma  of  the  Cheek.    Excised  with  the  Electric  Cautery  and  Base 
Cauterized  with  Hot  Soldering  Irons. 

It  should  be  very  liberal  and  the  defect  caused  should  be  covered  by  means  of 
a  plastic  operation  so  that  the  resulting  scars  will  interfere  as  little  as  possible 


Appearance  Two  Months  after  Excising  Tumor.     Plastic  Operation  Later  Performed 
WITH  Triangular  Flap  from  Cheek,  with  Excellent  Result. 


Extensive  Squamous  Carcinoma  of  Lower  Lip  Treated  by  Hot  Cauteet  Ieons  and 

Intensive  X-Eays. 


SURGERY  OF  THE  HEAD  149 

with  the  appearance  of  the  patient.  Especial  care  should  be  taken  to  avoid 
tension  upon  the  eyelids  because  this  will  result  in  an  irritation  of  the  con- 
junctiva, which  may  lead  to  serious  trouble.  By  transversely  suturing  wounds 
in  the  vicinity  of  the  eyelids  tension  upon  them  may  usually  be  avoided. 

During  the  past  ten  years  we  have  subjected  a  number  of  these  patients 
suffering  from  epithelioma  to  X-raj^  treatment  before  operation,  and  have 
foimd  that  perfect  recovery,  without  operation,  as  the  result  of  the  X-ray 
treatment  is  not  at  all  uncommon,  provided  the  epithelioma  is  superficial.  In 
any  case  in  which  an  epithelioma  can  be  removed  without  causing  great 
deformity,  and  especially  without  interference  with  the  eyelids,  we  never  use 
the  X-ray  at  the  present  time  until  after  the  wide  removal  of  the  growth. 

In  farming  communities  in  which  lumpy- jawed  cattle  frequently  exist,  the 
farmers  often  suffer  from  ulceration  upon  the  face  due  to  infection  hj  the  ray 
fungus.  These  ulcers  are  more  granular  than  epitheliomata,  and  show  less 
tendency  to  undermining  edges  than  syphilitic  ulcers.  These  facts,  together 
with  the  history  of  having  handled  cattle,  makes  the  diagnosis  of  actinomycosis 
probable. 

Such  ulcers  heal  amost  spontaneously  upon  the  use  of  potassium  iodide, 
90  grains  in  half  a  pint  of  milk  three  times  a  day  for  three  or  four  days,  with 
interruptions  of  one  week,  as  described  in  connection  with  the  treatment  of 
actinomycosis  elsewhere. 


PART  III 

SURGERY  OF  THE  NECK 


GENERAL  CONSIDERATIONS 

Lines  of  incision.  It  is  important  to  bear  in  mind  the  natural  lines  on  the 
surface  of  the  neck  in  planning  all  surgical  operations  in  this  region,  owing 
to  the  fact  that  unsightly  scars  are  a  source  of  distress  to  the  patient  and 
annoyance  to  the  surgeon. 

Incisions  in  the  direction  of  the  sterno-cleido-mastoid  muscle  are  usually 
less  evident  from  scars  than  those  extending  at  an  angle  with  this  structure, 
or  across  it.  This  is  true  especially  if  the  incision  follows  either  the  anterior 
or  the  posterior  border  of  the  muscle. 

Incisions  extending  across  the  neck  should  be  uniform  on  both  sides  if 
possible. 

TRAUMATISM  OF  THE  NECK 

The  most  common  serious  traumatism  is  cut-throat  inflicted  by  the  patient 
himself  during  an  attempt  at  suicide,  or  by  some  enemy. 

In  all  of  these  cases  careful  hemostasis  and  adequate  drainage  are  elements 
which  must  be  provided  for  in  order  to  obtain  reasonably  good  results. 

Until  hemostatic  forceps  and  ligatures  can  be  applied  the  bleeding  may 
be  controlled  by  placing  the  ends  of  the  fingers  upon  the  bleeding  vessels. 
Only  rarely  will  it  be  possible  to  reyjair  the  wound  in  the  side  of  a  vessel.  .  In 
case  one  deep  jugular  vein  is  entirely  severed  the  patient  will  usually  die  from 
loss  of  blood  before  the  surgeon  arrives,  but  if  it  should  ever  happen  that  the 
surgeon  appeared  in  time  to  find  a  patient  still  alive,  with  one  deep  jugular 
vein  entirely  cut  and  the  other  one  nicked,  an  attempt  to  repair  the  injury 
in  the  second  vessel  would  be  proper. 

When  the  pneumogastric  nerve  has  been  severed  the  patient  is  at  once 
in  a  hopeless  condition  from  hemorrhage  from  the  deep  jugular  vein  and 
the  carotid  artery  before  help  can  be  obtained,  consequently  this  condition 
need  not  be  discussed  at  this  point. 

INJURY  TO  THE  TRACHEA 

When  the  trachea  has  been  cut  the  patient  usually  coughs  and  struggles 
so  violently,  because  of  the  fact  that  he  fills  his  trachea  with  blood  with  every 
inspiration,  that  it  is  difficult  to  control  the  hemorrhage.  It  is,  therefore, 
best  to  place  the  patient  in  the  prone  position,  and  if  this  is  not  possible,  in 
the  sitting  posture,  to  make  digital  compression  of  the  bleeding  vessels  and 
then  to  control  the  hemorrhage  with  hemostatic  forceps.  The  trachea  should 
then  be  carefully  sutured  with  fine  chromic  catgut,  then  the  vessels  should  be 
ligated, 

151 


152  SQRGERY  OF  THE  NECK 

An  abundance  of  tubular  and  gauze  drainage  should  be  inserted,  the 
cut  muscles  and  fascia  and  the  overlying  skin  should  be  sutured  and  a  dressing 
applied. 

It  is  seldom  possible  to  unite  the  cut  trachea  so  accurately  that  no  infec- 
tion takes  place  in  the  wound.  If  the  wound  in  the  trachea  is  irregular  it 
may  not  be  possible  to  close  it.  In  that  case  an  intubation  tube  should  be 
inserted,  the  wound  about  this  should  be  tamponed  with  gauze  and  the 
remainder  of  the  operation  carried  out  as  described  before. 

CRUSHING  INJURIES   OF   THE  NECK 

Crushing  injuries  may  be  so  severe  as  to  cause  fractures  of  the  larynx  or 
the  cartilages  of  the  trachea. 

In  the  event  of  dyspnea  due  to  the  collapse  of  these  structures,  or  to  the 
edema  following  the  injury,  this  must  be  overcome  either  by  the  introduction 
of  an  intubation  tube,  which  will  at  once  provide  a  passage  for  the  air  and  a 
splint  for  the  support  of  the  injured  structures,  or  if  the  injured  part  cannot 
be  reached  in  this  manner,  tracheotomy^  and  the  introduction  of  a  tracheotomy 
tube  should  be  employed. 

The  tube  should  be  removed  daily  after  the  third  day,  to  determine  experi- 
mentally whether  the  tissues  have  recovered  sufficiently  to  make  it  safe  to 
discard  the  artificial  aid.  The  patient  must,  however,  be  carefully  and  con- 
stantly watched  for  at  least  twenty-four  hours  after  it  seems  safe  to  remove 
the  tube  permanently. 

Many  of  these  patients  do  much  better  if  kept  in  a  sitting  posture.  If 
tracheotomy  is  performed  the  canula  should  be  kept  covered  with  two  to  four 
thicknesses  of  moist  gauze. 

CYSTS  OF  THE  NECK 

Sebaceous  cysts  occur  here  as  in  all  other  portions  of  the  body  and  must 
be  treated  by  total  excision,  the  same  care  being  taken  to  prevent  leaving 
any  part  of  the  lining  membrane  here  as  elsewhere. 

Dermoid  cysts  occur  in  the  same  way  as  elsewhere,  the  many  important 
changes  that  take  place  during  fetal  life  in  this  region  making  their  occurrence 
somewhat  frequent,  although  these  fetal  remnants  or  inclusions  in  this  region 
usually  take  the  form  of  branchial  cysts  or  thyroglossal  cj^sts. 

The  treatment  consists  in  careful,  complete  excision. 

Aside  from  these  cj^sts  we  encounter  lymphangiomata,  bursa,  hydrocele, 
blood  cysts  (aside  from  cysts  of  the  thj-roid  gland)  and  hydatid  cysts. 

BRANCHIAL  CYSTS 

During  the  early  development  of  the  embrj'o  there  are  four  clefts  on 
each  side  of  the  neck  corresponding  to  the  gills  in  fishes.  These  later  become 
obliterated,  but  occasionally  the  laj-ers  do  not  unite  perfectly  and  there  are 
left  portions  of  the  epiblastic  tisue  which  have  not  been  destroyed  and  which 
later  secrete  a  fatty  substance  which  will  accumulate  in  this  defect  and 
presently  form  what  is  known  as  a  branchial  cyst. 

The  cyst  develops  slowly,  is  located  underneath  the  skin  and  superficial 
fascia,  fluctuates  upon  palpation,  and  is  not  inflammatory  in  character. 

The  incision  is  advisably  made  over  the  cyst  in  the  direction  of  some 
of  the  longer  lines  of  the  neck,  and  upon  approaching  the  growth  a  point  will 
be  reached  where  there  is  a  longer  line  of  cleavage  between  the  tissues. 
By  separating  the  cyst  from  the  surrounding  tissues  through  this  latter  it 


SURGERY  OF  THE  NECK  153 

can  be  easily  removed.  The  wound  is  closed  in  tlie  customary  manner  and 
it  heals  kindly.  By  finding  the  natural  line  of  cleavage  one  can  remove  the 
growth  without  any  danger  of  injuring  the  deep  jugular  vein,  in  whose 
proximity  it  exists,  and  even  if  there  has  been  an  inflammatory  condition 
which  has  resulted  in  adhesions  to  the  deep  jugular  vein  the  growth  may 
readily  be  removed  by  careful  dissection  without  danger. 

What  has  just  been  said  may  be  applied  to  all  the  other  cysts  men- 
tioned, with  the  exception  of  those  of  the  thyroid  gland,  which  will  be  con- 
sidered later,  and  the  hydatid  cyst  which  is  due  to  a  parasite  and  which  may 
occur  between  the  layers  of  any  of  the  structures  of  the  neck.  This  latter 
form  will  be  recognized  by  the  fact  that  within  a  capsule  of  connective  tissue 
there  is  a  second  cyst  which  is  no  part  of  the  human  body,  but  of  the  parasite. 
This  will  peel  out  spontaneously  as  soon  as  the  connective  tissue  covering  is 
open,  for  there  is  no  connection  between  the  two  structures. 

THYROGLOSSAL  CYST 

In  some  cases  the  thyroglossal  duct  has  failed  to  become  obliterated  during 
fetal  life  and  having  a  mucous  lining  it  continues  to  secrete  mucus,  which 
may  be  emptied  either  through  an  opening  at  the  external  end  of  the  duct 
opposite  the  prominence  of  the  thyroid  cartilage,  or  into  the  mouth  through 
its  opening  at  its  inner  end  opposite  the  hyoid  bone,  or  both  ends  may  dis- 
charge this  mucus,  forming  a  thyroglossal  fistula. 

Again  both  ends  may  be  closed  and  a  thyroglossal  cyst  form.  In  either 
event  the  only  treatment  promising  relief  consists  in  the  complete  excision 
of  every  portion  of  the  mucous  lining. 

This  lining  is  extremely  delicate  and  it  is  possible  to  make  a  complete 
dissection  only  if  the  very  greatest  care  is  exercised.  This  is  true  especially 
because  the  canal  is  frequently  not  straight  and  the  cyst  wall  often  forms 
irregular  pockets.  The  dissection  may  be  facilitated  by  injecting  melted 
paraffin  (melting  point  of  110°  F.)  into  the  sinus,  permitting  this  to  harden 
and  then  removing  the  cyst  or  sinus  with  its  paraffin  plug. 

The  outer  opening  is  grasped  with  fine  forceps  and  the  skin  surrounding 
the  osteum  is  excised,  together  with  the  lining  of  the  entire  sinus  or  cyst, 
care  being  taken  to  remain  outside  of  the  cyst  throughout  the  operation. 

GOITRE 

Until  recently  it  has  generally  been  supposed  that  in  this  country  patients 
suffering  from  goitre  rarely  aff'ord  a  characteristic  history  such  as  they 
give  in  portions  of  Switzerland,  France  or  Wales,  where  certain  regions  seem 
to  furnish  a  very  large  proportion  of  patients,  while  other  regions  are  rela- 
tively free  from  them. 

Apparent  cause.  Since  goitre  has  been  studied  more  carefully  in  this 
country  many  regions  have  been  found  where  this  disease  abounds  and 
recently  a  number  of  farms  have  been  investigated  each  supplied  by  a  single 
well  which  has  seemed  to  cause  the  appearance  of  goitre,  especially  in  the 
younger  members  of  the  family,  from  drinking  the  water.  Families  having 
been  quite  free  from  this  disease  have  taken  up  their  homes  upon  these  farms, 
and  within  a  year  several  members  thereof  have  become  afflicted,  then  chang- 
ing their  residence  the  children  who  were  born  later  remained  free  from  the 
disease. 

The  investigations  described  in  the  TJ.  S.  Public  Health  Reports,  April  14, 
1914,  have  given  such  clear  and  positive  results  that  it  seems  proper  to  repeat 
here  the  most  striking  points,  because  a  knowledge  of  these  facts  will  aid 


154 


SURGERY  OF  THE  NECK 


the  surgeon  in  instituting'  prophylactic  measures  as  well  as  in  properly  direct- 
ing the  after-treatment.  These  investigations  show  that  goitre  occurs  in 
regions  in  which  the  drinking  water  is  soft,  as  well  as  in  those  in  which 
it  is  hard,  and  also  that  there  is  no  clinical  evidence  that  dissolved  salts  cause 
goitre. 

Goitrous  water  may  be  radio-active  and  it  may  contain  much  carbon 
dioxide.     Goitre  may  be  due  to  much  iodine  in  drinking  water. 

There  seems  to  be  a  direct  relationship  between  the  affection  and  the 
degree  of  bacterial  contamination  of  water  supply. 


Diffuse  Colloid  Adenoma  of  the  Thyroid  Gland.     Treatment — Excision  of  %  of 

All  Lobes. 


Experimentally  goitre  M^as  produced  in  man  by  water  from  a  goitrous 
stream.    By  giving  the  same  water  boiled,  goitre  was  not  produced. 
MacCorrison  gives  the  following  conclusions : 

1.  Goitre  can  be  produced  in  a  few  weeks  by  suspended  matter  separated 
by  filtrations  from  goitre-producing  waters. 

2.  Thyroid  enlargement  cannot  be  so  produced  when  the  sediment  is  boiled. 

3.  Goitre  so  produced  cannot  be  due  to  mineral  matter  but  is  due  to  a 
living  organism. 

4.  While  it  cannot  be  positively  stated  that  a  Berkfelt  filter  removes 
the  cause  of  goitre,  water  so  filtered  cannot  produce  goitre  within  fifty-six 
days,  which  was  the  period  of  the  experiment. 

These  conclusions  are  quite  in  keeping  with  those  of  Bircher  who  made 


SURGERY  OF  THE  NECK  155 

extensive  experiments  with  the  use  of  goitre  water  in  rats.    He  demonstrated 
the  following  facts : 

1,  That  centrifugalization  renders  the  pathogenic  water  innocuous. 

2.  That  addition  of  chemicals,  like  hydrogen  peroxide,  renders  the  patho- 
genic water  innocuous. 

3.  That  dialysis  removes  the  goitre-producing  substance  from  the  water. 

4,  That  substances  separated  by  the  membrane  of  the  dialysis  can  produce 
the  disease. 

As  a  result  of  Bircher's  experiments  the  city  of  Rapperswyl,  in  Switzer- 
land, in  which  70  per  cent,  of  all  natives  had  goitres,  was  freed  completely 
from  endemic  goitre  by  taking  the  water  supply  from  a  region  in  which 
there  is  only  granite  rock,  while  it  was  previously  taken  from  a  region 
which  had  been  covered  by  the  ocean  in  former  ages.  Whether  the  heat 
(which  melted  the  sand  into  granite)  caused  this  dilference  it  is  difficult  to 
say. 

One  of  the  instances  quoted  frequently  shows  the  influence  of  this  infected 
water  so  clearly  that  it  seems  wise  to  repeat  it  here. 

Example.  Two  private  schools  located  only  a  few  miles  from  each  other 
obtained  their  drinking  water  from  two  dilferent  springs.  Both  schools 
obtained  their  pupils  from  many  distant  points.  The  pupils  of  one  of  these 
schools  developed  goitre  regularly  while  the  pupils  of  the  other  school  as 
regularly  remained  free  from  goitre.  "When  the  water  supply  of  the  first 
school  was  changed  the  pupils  also  remained  free  from  goitre  while  attend- 
ing this  institution. 

Kocher  likewise  claims  that  if  water  is  boiled  it  loses  thereby  its  infec- 
tious character  and  becomes  quite  as  harmless  as  that  from  any  pure  source. 
Whether  this  is  due  to  the  precipitation  of  lime  salts  contained  in  the  water, 
or  to  some  micro-organisms,  has  not  yet  been  determined. 

It  seems,  however,  imperative  that  families  in  Avhich  several  goitres  have 
occurred  be  advised  to  use  water  for  drinking  purposes  from  an  entirely 
different  source  of  supply,  or  else  that  they  invariably  boil  all  drinking  water 
from  the  well -which  is  supposed  to  have  caused  the  goitres  already  developed. 

Characteristics.  The  enlargement  of  the  thyroid  gland  more  commonly 
appears  about  the  age  of  puberty  than  at  any  other  time.  It  also  occurs 
during  gestation  in  quite  a  number  of  patients.  It  happens  much  more  fre- 
quently in  this  country  in  females  than  in  males.  It  may  afifect  any  one  or 
two,  or  all  of  the  lobes  of  the  thyroid  gland,  although  the  right  lobe  is  most 
frequently  the  largest.  When  the  middle  lobe  is  involved  there  is  frequently 
an  enlargement  extending  down  behind  the  upper  end  of  the  sternum,  causing 
quite  severe  pressure  upon  the  anterior  surface  of  the  trachea.  The  patient 
may  seek  relief  because  of  the  deformity  caused  by  the  presence  of  the  tumor -^ 
because  of  its  weight  on  the  neck;  or  because  of  the  obstruction  in  the  trachea 
produced  by  pressure  from  a  lobe  of  this  gland.  The  enlargement  naay  be 
due  to  an  increase  in  the  parenchyma  of  the  gland,  or  one  of  the  lobules  may 
be  distended  with  gelatinous  or  serous  fluid  giving  rise  to  the  formation  of 
a  cyst,  or  there  may  be  a  fibrous  degeneration  of  a  portion  of  the  gland  or  the 
development  of  a  fibrous  tumor,  or,  especially  in  patients  advanced  in  age, 
there  may  de^^elop  a  malignant  growth,  either  carcinoma,  sarcoma,  endothe- 
lioma or  angioma.  The  enlargement  may  also  be  due  to  a  simple  infection, 
with  its  skin  edema. 

Diagnosis.  The  diagnosis  of  a  tumor  of  the  thj^'oid  is  simple  because 
of  the  form  and  location  of  this  gland;  also  from  the  fact  that  if  the  patient 
swallows  the  gland  rises  with  the  larynx,  being  firmly  attached  to  the  trachea. 
An  enlargement  due  to  an  inflammatory  condition  can  be  easily  recognized 
because  of  the  symptoms  accompanying  inflammatory  conditions  in  any  part 


156  SURGERY  OF  THE  NECK 

of  the  body.  Malignant  growths  are  characterized  by  an  induration  of  the 
tissues,  which  is  not  present  in  a  benign  growth  of  the  thyroid  gland.  The 
age,  and,  usually,  a  rapid  development  of  cachexia,  are  important  conditions 
to  be  considered  in  making  this  differential  diagnosis. 

Hygiene  and  internal  medication.  In  young  girls  the  glandular  enlarge- 
ment commonly  subsides  if  general  hygienic  measures  are  employed.  This 
may  be  somewhat  facilitated  by  administering,  three  times  a  day,  tablets 
containing  five  grains  each  of  the  desiccated  thyroid  gland  of  sheep,  the 
doses  being  somewhat  varied  according  to  the  condition  of  the  patient.  Gen- 
eral tonics  are  indicated  in  these  cases.  In  older  patients  the  absorption 
of  these  growths  is  sometimes  further  facilitated  by  the  hypodermic  injection 
of  from  sixty  to  one  hundred  and  twenty  drops  of  a  five  per  cent,  solution  of 
carbolic  acid  in  water,  directly  into  the  enlarged  lobe.  This  should  be  done 
once  each  week  at  first  and  less  frequently  later  on.  The  same  hygienic  and 
tonic  measures  should  be  emploj^ed  as  in  younger  patients. 

Indications  for  surgical  treatment.  Where  the  goitre  increases  in  size  not- 
withstanding the  hygienic,  dietetic,  medicinal  and  injection  treatment  just 
named  surgical  removal  of  the  gland  may  be  indicated,  provided  the  patient 
suffers  because  of  the  incident  pressure,  from  pain,  dyspnea,  interference 
with  the  recurrent  laryngeal  nerve  or  in  case  the  weight  of  the  part  becomes 
burdensome  or  the  deformity  repulsive. 

EXOPHTHALMIC  GOITRE 

From  the  standpoint  of  the  surgeon  the  diagnosis  of  exophthalmic  goitre, 
in  cases  coming  properly  under  surgical  treatment,  is  not  a  difficult  matter 
because  no  case  properly  belongs  in  this  class  unless  treatment  with  rest, 
hygiene,  diet  and  internal  medication  has  either  failed  altogether  or  has  failed 
to  relieve  the  patient  permanently  of  the  disease. 

As  early  as  1786  Parry  gave  a  clear  description  of  the  symptoms  of  this 
disease.  This  was  repeated  by  Graves  in  1835  and  five  years  later  with  great 
clearness  by  Von  Basedow,  and  since  then  innumerable  times  by  hundreds 
of  clinicians. 

The  following  may  serve  as  a  short,  concise  summary  of  the  symptoma- 
tology. 

Summary  of  characteristic  symptoms.  1.  Exophthalmos.  2.  Tachycardia. 
3.  Tremor.  4.  Muscular  weakness.  5.  Nervous  excitability.  6.  Vertigo. 
7.  Graef's  signs  (in  directing  the  eye  downward  the  lower  margin  of  the 
upper  eyelid  does  not  follow  the  line  of  vision  normally,  but  lags  behind 
or  follows  in  an  irregular  spastic  manner).  8.  Stellwag's  sign  (retraction 
of  upper  lid  together  with  infrequent  winking).  9.  Paroxysmal  dyspnea. 
10.  Intermittent  vomiting  without  apparent  exciting  cause.  11.  Intermittent 
diarrhea  without  apparent  exciting  cause.  12.  Intermittent  sweating  with- 
out apparent  exciting  cause.  13.  Intermittent  mental  depression  without 
apparent  exciting  cause.  14.  Psychic  excitation  increases  the  gravity  of  the 
condition.  15.  Physical  or  mental  fatigue  increases  the  gravity  of  the  con- 
dition. 16.  The  administration  of  thyroid  extract  increases  the  gravity  of 
condition.  17.  The  administration  of  iodides  increases  the  gravity  of  the 
condition.     18.  In  advanced  cases  there  is  practically  always  emaciation. 

Any  one,  or  any  group,  of  these  symptoms  may  be  prominent  early, 
while  others,  especially  the  goitre  and  the  exophthalmos  may  be  late  in 
appearing,  or  may  be  developed  to  so  slight  an  extent  that  they  are  only 
noticed  after  the  examining  physician's  suspicion  of  the  presence  of  the  disease 
has  been   aroused   by  the  prominence  of  some   of  the   less   common  condi- 


SURGERY  OF  THE  NECK 


157 


tions.    The  one  symptom  of  tachycardia,  however,  seems  to  be  present  in  every 
case. 

Blood  analysis.  Kocher  has  found  some  fairly  uniform  conditions  in  the 
blood  examinations  made  in  cases  suffering  from  exophthalmic  goitre,  but 
they  are  also  present  in  a  number  of  other  diseases.  There  seems  to  be  lessened 
coagulability  of  the  blood;  the  polyneutrophiles  are  decreased  from  75  per 
cent,  to  35  per  cent.,  while  the  lymphocytes  are  increased  from  25  per  cent, 
to  75  per  cent,  in  individual  cases   on  the  day  before   operation,  while   on 


Exophthalmic  Goitre  in  a  Girl  of  21  Yeaes.  Tumor  Peesent  Since  Age  of  13  Years.  Symp- 
toms Progressed  Very  Eapidly  during  the  Past  Year.  Operation — Excision  of  the 
Eight,  Median  and  %  of  the  Left,  Lobes. 

the  day  after,  the  neutrophiles  increased  from  42  per  cent,  to  89.2  per  cent., 
whereas  the  lymphocytes  decreased  from  48  per  cent,  to  2.7  per  cent. 

Kocher  comes  to  the  conclusion  that  there  is  an  increase  in  lymphocytes 
and  a  decrease  in  neutrophiles  before  the  operation  and  vice  versa  after  opera- 
tion. He  characterizes  exophthalmic  goitre  as  a  hyperthyreosis  with  glandular 
hj'perplasia,  lymphocytosis  and  Ij'-mphatic  disturbances  of  the  gland. 

The  increase  in  lymphocytes,  however,  was  more  often  relative  than  abso- 
lute ;  the  total  number  of  leucocytes  being  normal  or  rather  low. 

Value  of  early  diagnosis.  From  the  practical  standpoint,  however,  it 
should  be  stated  that  the  diagnosis  is  made  in  almost  every  case  a  long  time 
before  the  surgeon  is  consulted.  Indeed,  until  very  recently,  too  long  a 
period  of  time  has  intervened  between  the  original  diagnosis  and  the  surgical 
treatment  in  many  of  these  cases,  and  too  much  stress  cannot  be  laid  upon 


158 


SURGERY  OF  THE  NECK 


the  importance  of  an  early  operation  in  all  instances  in  which  a  permanent 
cure  is  not  obtained  by  internal  treatment  pursued  a  reasonable  length  of 
time ;  provided,  first,  that  the  patient  is  not  suffering  from  temporary  exacer- 
bation of  the  hyperthyroidism,  and,  second,  that  the  disease  has  not  existed 
sufficiently  long  to  leave  the  circulation  and  the  nervous  system  of  the  patient 
in  an  absolutely  hopeless  condition.  Unless  one  recognizes  the  first  of  these 
contra-indieations  one  will  lose  patients  who  could  easily  bear  the  strain 
of  the  operation  were  they  not  also  compelled  to  bear  the  additional  strain 
of  the  temporary  hyperthyroidism.  This  can  be  avoided  by  waiting  until 
the  temporary  storm  has  subsided.     In  the  vast  majority  of  these  cases  one 


Diffuse  Toxic  Adenoma  of  the  Thyroid  Gland. 


will  find  that  such  exacerbations  have  repeatedly  occurred  before,  only  to 
subside  again  under  treatment  with  physical,  mental  and  emotion-rest,  proper 
diet  and  internal  treatment.  Of  course,  the  patient  each  time  emerges  from 
such  an  attack  in  a  worse  condition  than  previously,  consequently  one  shows 
better  judgment  by  avoiding  operations  during  an  attack  of  acute  hyperth}'- 
roidism. 

This  fact  is  most  forcibly  insisted  upon  by  Kocher,  Mayo  and  all  other 
clinicians  who  have  had  a  large  experience  in  the  surgical  treatment  of  these 
cases,  and  is  one  that  should  be  especially  impressed  on  the  family  physician. 

Youthful  patients.  It  is  well  to  bear  in  mind  that  especially  in  young 
girls,  about  the  time  of  puberty  or  a  little  later,  many  goitres  cause  symptoms 
which  will  justify  a  diagnosis  of  incipient  exophthalmic  goitre.     The  tremor, 


SURGERY  OF  THE  NECK 


159 


the  muscular  weakness,  the  nervous  excitability,  some  tachycardia  and  many 
of  the  minor  symptoms  are  often  present.  There  may  even  be  a  very  slight 
degree  of  exophthalmos,  and  still  these  patients  will  almost  invariably  recover 
without  operation  under  physical,  mental  and  emotional  rest ;  a  diet  com- 
posed largely  of  milk,  cooked  vegetables  and  fruits:  favorable  hygienic  sur- 
roundings ;  and  absence  of  conditions  which  might  cause  nervous  excitement. 
It  is  well  to  bear  this  in  mind  because  it  will  prevent  many  unnecessary 
operations. 


Omo  -  hyoij  f?T- 

ItjsefTfon    of-  _ 
iSttrno-thyro'td    M 
on  Thvi-oid  C^art. 


ThyoLd   <^land 

Pyramidal    lobe  o/" 
Thynoid  (f/ond 


^Tftrno-thf/roid 


fo^Tbr/or 

belly     cf- 
Omo-hyoid  Iff^ 

C'fsvic'u/sr  and 
^tetndl  ofi^itrd  of 

^Tetno  -C^/eldo-  ^a  i'^  /V 


Hyai'd    bone 
Tafia/  ArTcry 

LinqUil    Artery 

—Ihftaid    d^rTila^e 

Ou.fl.  Thyroid  (\^t. 

Int.  Ja^ukr    Vo 
L  ommorj   Carotid 


Cricoid  C^rti'Ug? 

^^yroid    (!jlind 
\nedurtent' 


yn^t 


I  ??. 


J»^ular    Vilrr 


C'/qv^c'/c 


iStertfo  ~  Thyro/^  fr^. 


■Xty/erlo r    TTiyro id  A. 
Tram    Thyrct<d  /^/is) 

ifec'urrenr    Ldrynse^/ ff. 
—  Denn/i  k).  drile  —  Ifif-  ~ 


The  Thyroid  Gland  and  Its  Eelatioxs. 

The  structures  are  shown  as  though  transparent,  the  muscles  of  the  left  side  having  beeu 
removed,  showing  the  left  lobe  of  the  thyroid  gland,  with  the  recurrent  laryngeal  nerve  and 
the  iuferior  thyroid  artery  behind  it. 

Although  much  attention  has  been  given  to  the  complications  affecting 
the  nervous,  the  circulatory  and  the  digestive  systems,  because  of  their  being 
directly  dependent  upon  the  disease,  it  must  be  remembered  that  exophthalmic 
goitre  is  not  uncommonly  complicated  by  diseases  of  any  portion  of  the 
body.^  Even  myxedema  has  been  described  as  a  complication  by  Simonds, 
Gooding,  Faure  and  a  few  others,  although  such  disease  is  plainly  the  result 


160  SUEGERY  OF  THE  NECK 

of  a  lack  of  physiological  activity  of  the  thyroid  gland,  while  exophthalmic 
goitre  is  supposed  to  be  due  to  a  hyperthyroidism,  according  to  Kocher,  or 
to  a  toxin  caused  by  an  excessive  amount  of  normal  or  abnormal  thyroid 
secretion,  according  to  Moebius,  while  Oswald  and  a  few  others  think  there 
is  a  thyroid  insufficiency.  To  our  minds  the  beautiful  description  of  patho- 
logical findings  by  McCallum  are  convincing  of  the  fact  that  there  is  indeed 
always  a  condition  present  which  must  result  in  hyperthyroidism,  no  mat- 
ter what  the  exciting  cause  may  be,  and  this  we  think  is  plainly  borne  out 
by  the  clinical  picture. 

In  order  to  produce  a  clear  idea  of  a  reasonably  safe  operation  in  exoph- 
thalmic goitre  it  may  be  well  to  describe  the  various  steps  successively. 

Pre-operative  treatment.  It  is  important  to  prepare  those  with  a  pulse 
120  or  over  or  with  a  pulse  Avhich  lacks  uniformity,  by  absolute  rest  in 
bed,  mild  sedatives,  a  meat-free  but  nourishing  diet,  quiet  surroundings, 
absence  of  all  psychic  excitation,  which  according  to  the  observations  and 
animal  experimentations  of  Crile  is  capable  of  producing  hyperthyroidism  by 
a  discharge,  in  some  way  either  directly  or  indirectly,  into  circulation  of  an 
excessive  amount  of  thyroid  secretion,  which  in  itself  may  cause  death. 

Four  grains  of  hydrobromate  of  quinine,  in  capsules,  given  after  meals 
three  times  daily,  seems  to  be  of  some  benefit  in  the  preparatory  treatment 
of  these  cases.  A  considerable  proportion  may  improve  so  much  under  this 
treatment  that  an  operation  may  become  unnecessary. 

Tepid  baths  and  any  other  means  of  making  the  patient  comfortable  and 
contented  are  useful.  If  general  anesthesia  is  employed  this  should  be  given 
so  as  to  not  excite  the  patient. 

In  order  to  prevent  infection  two  precautions  are  important ;  first,  the 
careful  covering  of  the  patient's  hair,  and  second,  guarding  against  infection 
from  the  mouth  and  nose.  It  is  an  easv  matter  for  a  patient  to  fill  her  own 
wound  with  infectious  material  from  her  mouth,  or  nose,  if  these  are  not 
under  the  careful  supervision  of  some  assistant  who  gives  his  entire  atten- 
tion to  this  matter.  If  the  operation  is  performed  under  cocaine  anesthesia 
this  protection  can  readily  be  accomplished  bv  placing  a  dozen  thicknesses 
of  sterile  gauze  in  the  form  of  a  roller  bandage  over  the  patient's  mouth 
and  nose  and  around  the  head.  The  patient  will  be  able  to  breathe  through 
this  covering  but  the  air  expelled  from  the  nose  and  mouth  will  be  filtered  on 
its  way  through  these  layers  of  gauze. 

Anesthesia.  The  careless  use  of  anesthetics  in  this  operation  is  one  of 
the  greatest  dangers,  because  of  the  slight  margin  of  safety,  and  because  of 
the  poisonous  effect  of  all  anesthetics,  except  ether;  also  because  of  the  fact 
that  respiration  is  often  interfered  with  to  some  extent  by  the  manipula- 
tions of  the  operation,  and  because  mucus  is  likely  to  accumulate  in  the  larynx 
during  the  operation. 

One  per  cent,  of  cocaine  injected  carefully  into  the  skin  along  the  line 
of  incision,  and  along  the  course  of  the  nerves  supplying  the  field  of  opera- 
tion will  remove  the  necessity  of  an  anesthetic,  and  has  the  advantage  of 
compelling  the  surgeon  to  be  gentle  in  his  manipulations,  but  it  has  the  dis- 
advantage of  operating  with  the  patient  in  a  conscious  condition. 

If  one-fourth  of  a  grain  of  morphia  and  one  one-hundredth  of  a  grain 
of  atropia  are  administered  hypodermically  half  an  hour  before  the  opera- 
tion is  begun,  and  the  patient  is  then  thoroughly  anesthetized  with  ether  by 
the  drop  method;  and  if  then  the  head  of  the  table  is  elevated  so  that  the 
body  lies  at  an  angle  of  45  degrees,  the  operation  can  be  completed  without 
the  further  administration  of  ether.  This  makes  the  use  of  ether  perfectly 
safe,  and  the  patient's  pulse  regularly  improves  during  the  operation.  The 
jaw  must,  however,  be  held  forward  by  a  reliable  assistant  during  the  entire 


SUEGERY  OF  THE  NECK 


161 


operation  in  order  not  to  permit  the  tongue  to  obstruct  the  respiration  by 
falling  back  into  the  pharynx. 

Technique.  The  curved  transverse  symmetrical  incision  of  Kocher  is 
made  with  convexity  downwards;  its  lowest  portion  being  2  cm.  above  the 
upper  end  of  the  sternum.     The  skin  flap,  together  with  the  platysma,  is 


Thyroidectomy. 

Showing  large  incision  with  primary  ligation  of  superior  thyroid  artery  and  vein  at  c; 
the  retracted  sterno-cleido^mastoid  muscle  at  &  and  the  dislocated  gland  a. 

reflected  upward  to  a  point  just  above  the  upper  attachment  of  the  sterno- 
thyroid muscles.  These  are  now  cut  across  at  their  upper  end  and  reflected 
downward.  This  gives  an  excellent  field  of  operation.  It  is  now  possible  to 
grasp  the  superior  thyroid  vessels  between  two  pairs  of  forceps  and  to  cut 

and  ligate  both  ends. 

11 


162  SURGERY  OF  THE  NECK 

In  the  meantime  the  superficial  vessels  which  have  been  encountered  have 
all  been  grasped  between  two  pairs  of  hemostatic  forceps  and  have  been  cut 
and  ligated. 

Having  severed  the  superior  thj-roid  vessels  on  the  side,  of  course,  on 
which  an  enlargement  is  found  or  on  which  there  are  irregular  nodules  to 
which  the  disease  has  been  attributed,  it  is  an  easy  matter  to  dislocate  the 
lobe  forward.  This  brings  into  view  the  inferior  thyroid  vessels.  These  are 
then  grasped  between  two  pairs  of  hemostatic  forceps,  then  cut  and  ligated. 

At  this  point  it  is  very  important  not  to  grasp  the  vessels  too  near  their 
origin,  especially  on  the  right  side,  for  fear  of  injuring  the  recurrent 
laryngeal  nerve  or  the  lower  one  of  the  parathyroid  glands.  Both  of  these 
structures  are  located  between  the  thyroid  gland  and  the  trachea  near  this 
point,  and  both  may  easily  be  avoided  if  the  above  plan  is  followed. 

The  lobe  is  then  dissected  up,  care  being  taken  to  leave  the  posterior 
portion  of  the  capsule  undisturbed  and  with  it  the  recurrent  laryngeal  nerve 
and  parathyroid  gland.  The  isthmus  is  now  lifted  up  and  this  exposes  the 
inferior  thyroid  vessels  of  the  other  side.  These  should  usually  be  treated 
precisely  as  those  on  the  side  which  has  just  been  finished,  unless  the  disease 
is  entirely  confined  to  the  one  side.  In  most  instances  it  is  best  to  remove  one 
entire  lobe,  Avith  the  exception  of  the  posterior  capsule.  The  isthmus  and 
about  the  lower  half  of  the  other  lobe  should  usually  be  removed,  also  without 
disturbing  the  posterior  capsule.  This  applies  only  to  cases  whose  margin  of 
safety  is  sufficient  to  make  so  extensive  an  operation  safe.  In  case  of  doubt 
one  lobe  only  is  removed  at  the  first  operation  and  if  this  seems  too  much  one 
or  two  groups  of  vessels  are  ligated  and  the  excision  of  the  gland  is  made  at  a 
later  time. 

This  disposes  of  both  inferior  thyroid  arteries  and  veins  as  well  as  the 
superior  vessels  on  one  side.  During  the  entire  operation  all  manipulations 
are  made  with  the  greatest  gentleness  in  order  not  to  press  contents  of  the 
gland  into  the  circulation  or  into  the  wound  for  fear  of  causing  acute 
hj^perthyroidism. 

At  the  same  time  great  care  is  taken  to  prevent  hemorrhage,  because 
Kocher  has  pointed  out  the  toxic  effect  of  blood  absorbed  by  the  wound 
surfaces.  For  the  same  reason  every  precaution  is  taken  to  stop  any  oozing 
into  the  wound  after  the  operation. 

The  muscles  are  then  carefully  sutured  in  place  so  as  to  reduce  the 
deformity  to  a  minimum.  A  small  drain  is  inserted  through  the  lowest  point 
in  the  wound,  or,  better  still,  through  a  small  opening  2  cm.  below.  The 
skin  wound  is  closed  with  the  greatest  accuracy  in  order  to  prevent  deformity. 

There  is  practically  always  a  sufficient  amount  of  serum  secreted  to  indi- 
cate the  use  of  good  drainage. 

What  has  been  said  concerning  the  technique  of  thyroidectomy  for  the 
relief  of  exophthalmic  goitre  is  true  of  the  operation  for  simple  goitre,  with 
the  one  difference  that  the  latter  class  of  patients  is  usually  in  a  much  better 
general  state  of  health.  The  greatest  amount  of  danger  in  the  former  class 
comes  from  the  effect  the  hyperthyroidism,  characterizing  the  disease,  has 
already  had  upon  the  tissues  of  the  patient's  nervous  and  circulatory  systems 
before  coming  under  the  care  of  the  surgeon. 

By  neglecting  all  of  the  precautions  advised  against  the  production  of 
hyperthyroidism  during  the  operation  it  is  possble  to  cause  this  condition 
occasionally  even  in  operations  for  the  relief  of  simple  goitre;  but  with  rea- 
sonable care  this  can  always  be  avoided. 

Supply  of  liquid.  Immediately  after  the  operation  it  is  well  to  supply 
an  abundance  of  liquid  to  the  patient  in  the  form  of  hot  water  taken  by 
mouth,  or  normal  salt  solution  given  as  an  enema  by  the  continuous  drop 


■^m 


SURGERY  OF  THE  NECK  163 

method,  or  if  neither  of  these  methods  can  be  applied,  by  subcutaneously 
injecting  normal  salt  solution  into  the  tissues  underneath  the  breasts.  This 
is  especially  useful  for  the  relief  of  post-operative  hyperthyroidism. 

Detail  of  minimal  dangers.  By  performing  this  operation  in  such  a  sys- 
tematic manner  the  dangers  to  the  patient  are  reduced  to  a  minimum. 
Indeed,  all  of  the  recognized  dangers  are  practically  eliminated.  Ether  anes- 
thesia which  is  permanently  stopped  before  beginning  to  operate,  removes 
all  danger  from  this  source.  It  also  disposes  of  the  danger  from  post-opera- 
tive ether  pneumonia  inasmuch  as  the  patient  exhales  practically  all  of  the 
ether  during  the  operation.  The  arrangement  of  the  gauze  bandage  on  the 
mouth  and  nose  prevents  infection  from  this  source.  Injury  to  parathyroids 
and  recurrent  laryngeal  nerves  is  carefully  avoided.  The  gentle  manipula- 
tions of  the  gland  and  accurate  hemostasis  prevent  difficulty  from  thyroid 
toxins,  and  the  remaining  portion  of  the  gland  prevents  cachexia  strumipriva. 

There  are,  however,  cases  which  are  too  weak  to  bear  even  this  simple 
operation  and  which  seem  to  be  nnable  to  make  further  progress  without 
operative  aid.  In  these  it  is  well  to  follow  the  suggestions  of  Kocher  to 
ligate  first  one  vessel  under  cocaine  and,  after  a  few  days,  another,  until  it 
seems  safe  to  remove  the  diseased  gland. 

Tuholsky  in  an  admirable  paper  suggests  the  plan  of  preventing  the 
toxic  effect  of  thyroid  secretion  by  ligating  both  superior  and  inferior  thyroid 
veins.  This  is  worthy  of  the  attention  of  experimental  research  laboratorj^ 
workers  in  this  field. 

Lowered  mortality.  For  statistics  the  contributions  of  Mayo,  Kocher 
and  Crile  should  be  consulted.  They  show  one  very  important  practical  point 
which  we  wish  to  emphasize,  in  connection  with  many  others,  namely,  that 
the  operative  mortality  has  decreased  enormously  both  with  the  accumula- 
tion of  the  total  surgical  experience  in  this  field  and  with  the  enlarged  sur- 
gical experience  of  each  individual  operator.  In  the  history  of  all  surgical 
progress  whenever  this  has  occurred  the  time  was  near  for  uniform  methods 
to  become  established. 

The  first  case  of  exophthalmic  goitre  we  personally  operated  has  now 
been  perfectly  well  since  1891.  The  patient  was  a  young  woman  twenty-two 
years  of  age,  with  typical  symptoms,  becoming  constantly  worse  under  internal 
treatment.  There  was  marked  exophthalmos,  severe  nervous  symptoms,  only 
a  moderatelj^  enlarged  nodular  lateral  lobe  and  marked  tachycardia.  Her 
pulse  had  remained  above  140  beats  per  minute  during  several  weeks  of 
observation  previous  to  operation. 

The  rapid  and  permanent  disappearance  of  all  of  these  symptoms  after 
operation  encouraged  us  to  employ  surgical  treatment  in  all  cases  which 
did  not  recover  permanently  by  internal  treatment,  and  such  a  course  has 
been  pursued  ever  since  that  time. 

Recent  advancements.  During  the  past  few  years  this  subject  has  been 
taken  from  the  field  of  experimental  surgery  and  placed  among  those  which 
are  looked  upon  as  fairly  well  settled  by  all  surgeons  who  have  had  an  oppor- 
tunity to  build  up  a  fair  clinical  experience  in  this  especial  branch.  This 
change  has  been  accomplished,  especially  during  the  past  few  years,  through 
the  investigations  of  the  internist  in  the  direction  of  diagnosis,  through 
the  physiologist  in  the  study  of  living  pathology  (largely  through  experi- 
mental work)  and  by  the  surgeon  in  simplifying  the  technique  of  surgical 
treatment.  So  thoroughly  have  all  these  points  been  studied  that  it  may 
now  be  reasonably  expected  that  the  primary  diagnosis  having  been  made, 
certain  cases  may  be  relieved  permanently  by  internal  treatment,  while  others 
will  be  improved  only  temporarily  by  internal  treatment,  and  that  this  latter 
class  should  be  subjected  to   surgical  treatment  at  an  early  stage   of  the 


164  SURGERY  OF  THE  NECK 

disease,  before  the  effects  of  the  toxins  have  hopelessly  impaired  especially 
the  muscles  of  the  heart  and  the  nervous  system.  Under  such  circumstances 
it  may  be  expected  that  there  will  remain  only  a  small  proportion  of  cases 
that  will  not  be  benefited  either  by  medical  or  surgical  treatment,  that  still 
a  smaller  proportion  of  the  extremely  violent  cases  will  succumb  to  the 
disease  without  an  operation,  and  only  a  very  small  percentage  die  after 
operation. 

Experience  has  shown  that  with  early  diagnosis  and  proper  selection  of 
cases  the  mortality  after  surgical  operation  is  extremely  small  and  that 
this  percentage  is  decreased  from  year  to  year  so  that  it  will  be  reasonable 
to  expect  an  operative  mortality  of  less  than  one  per  cent,  within  a  few 
years  in  the  hands  of  competent  surgeons. 

In  the  same  manner  unfavorable  late  results  are  sure  to  decrease,  as 
already  the  most  dreaded  ones  have  been  practically  eliminated.  "We  no 
longer  encounter  post-operative  cases  of  cachexia  strumipriva,  tetany,  paraly- 
sis of  the  vocal  cords,  and  but  very  rarely  recurrence  of  the  symptoms  of 
the  disease  itself. 

Conclusions.  1.  The  diagnosis  of  cases  of  exophthalmic  goitre  regarded 
as  suitable  for  surgical  treatment  is  relatively  easy  and  should  be  made  early. 
2.  All  cases  of  exophthalmic  goitre  which  are  not  relieved  permanently  by 
rest,  hygienic,  dietetic  and  medicinal  treatment  should  be  treated  surgically 
before  there  has  been  irreparable  harm  done  to  important  structures.  3.  This 
is  especially  to  be  borne  in  mind  in  connection  with  a  class  of  cases  that 
respond  readily  to  non-surgical  treatment  only  to  relapse  at  once  upon  the 
slightest  strain.  4.  The  dangers  of  the  operation  depend  largely  upon  the 
harm  done  by  the  disease  before  the  operation.  5.  These  dangers  may  be 
eliminated  by  early  operation  and  by  preliminary  treatment  with  rest,  hygiene 
and  diet.  6.  The  operative  danger  lies  in  the  anesthetic,  sepsis,  acute  hyper- 
thyroidism, tetany,  cachexia  strumipriva.  injury  to  the  recurrent  laryngeal 
nerve,  hemorrhage  and  shock.  7.  All  of  these  dangers  may  be  eliminated 
easily  with  reasonable  skill  and  attention  to  details.  8.  The  patient  should 
receive  carefully  directed  after-treatment,  with  rest,  hygiene  and  diet,  fol- 
lowing the  operation  until  especially  the  blood,  the  nervous  system  and  the 
heart  have  thoroughly  recovered  from  the  effects  of  the  disease.  9.  All 
psychic  excitation  should  be  prevented  before,  and  for  a  long  time  after,  the 
operation. 

After-treatment.  We  are  often  consulted  by  some  unfortunate  patient' 
who  considered  herself  so  completely  cured  by  the  removal  of  an  enlarged 
thyroid  gland  that  she  proceeded  to  indulge  in  the  same  physical,  mental, 
emotional  and  dietetic  excesses  which  may  have  had  much  to  do  Avith  the 
primary  disease.  In  many  cases  alcohol,  tobacco,  tea  and  coffee  have  been 
used  to  excess. 

It  is  extremely  important,  therefore,  to  give  these  patients  definite  direc- 
tions to  avoid  overwork,  excitement,  alcohol,  tobacco,  tea  and  coffee,  late 
hours,  social  and  business  worries  absolutely  and  permanently,  after  recov- 
ering from  the  operation,  and  to  select  a  diet  largely  composed  of  milk,  cooked 
vegetables  and  fruits.  We  make  it  a  rule  to  give  all  patients  the  following 
printed  list  of  directions  to  follow  after  they  return  to  their  homes,  and 
emphasize  thoroughly  the  fact  that  the  permanency  of  their  cure  depends 
largely  upon  the  care  with  which  they  carry  out  these  directions. 

Directions  to  the  patient  foUowinsr  operation  for  goitre.  It  is  of  the  very 
greatest  importance  that  the  following  directions  be  carried  out  as  nearly 
as  possible,  not  only  to  thoroughly  re-establish  health  and  strength,  but  also 
to  maintain  this  after  it  has  been  estaljlished,  because  the  causes  which 
brought  on  the  disease  in  the  first  place  frequently  produce  a  recurrence  if 


SURGERY  OF  THE  NECK  165 

the  same  errors  in  diet,  hygiene  and  physical,  mental  or  emotional  exhaustion 
are  again  committed. 

1.  Avoid  all  excitement  or  irritation,  like  attending  receptions,  shopping, 
church-work  and  politics.  If  anything  happens  to  annoy  you,  put  it  off  for  a 
week. 

2.  You  should  get  an  abundance  of  rest,  by  going  to  bed  early  and  taking 
a  nap  after  limcheon. 

3.  You  should  have  an  abundance  of  fresh  air  at  night,  consequently 
you  should  sleep  with  wide  open  windows,  or  on  a  sleeping  porch. 

4.  You  should  take  nothing  that  irritates  the  nervous  system,  like  tea, 
coffee,  or  alcohol.    Of  course  you  should  not  use  tobacco  in  any  way. 

5.  You  should  eat  very  little  meat.  If  you  are  very  fond  of  meat  take 
a  little  beef,  mutton  or  breast  of  chicken  or  fresh  fish  once  or  twice  a  Aveek 
or  at  most  three  times  a  week. 

6.  You  should  drink  a  great  deal  of  milk  or  eat  things  that  are  prepared 
with  milk,  such  as  milk-soup,  milk  toast,  etc.,  also  cream  and  buttermilk  are 
especially  good  for  you. 

7.  You  should  avoid  beef-soup  or  beef-tea  or  any  kind  of  meat  broths. 

8.  You  should  eat  an  abundance  of  cooked  fruits  and  cooked  vegetables, 
or  very  ripe,  raw  fruits,  or  drink  fruit  juices  prepared  out  of  ripe  fruits. 

9.  You  may  eat  eggs,  bread,  butter,  toast,  rice,  cereals. 

10.  You  should  drink  an  abundance  of  good  water,  or  if  this  is  not 
available  you  should  boil  your  drinking  water  for  twenty  minutes  or  drink 
distilled  water. 

MALIGNANT  GROWTHS  OF  THE  THYROID  GLAND 

Results  of  operations  unsatisfactory.  Operations  for  the  relief  of  malig- 
nant growths  of  the  thyroid  have  been  so  unsatisfactory  in  their  results  that 
it  seems  doubtful  whether  they  should  be  undertaken.  It  is  to  be  hoped 
that  our  experience  in  the  use  of  the  X-rays  will  continue  to  be  favorable 
in  these  cases,  but  at  the  present  time  nothing  positive  can  be  said  in  this 
regard.  If  a  removal  is  made  the  same  steps  are  to  be  carried  out  that  have 
just  been  described. 

In  several  cases  we  have  found  small  malignant  growths  in  what  was 
supposed  to  be  a  simple  goitre,  and  these  cases  have  been  free  from  recur- 
rence, but  in  those  in  which  the  diagnosis  was  possible  before  the  operation 
we  have  never  been  so  fortunate  and,  according  to  Crile,  this  has  been  the 
general  experience  of  surgeons. 

If  the  enlargement  in  the  thyroid  is  circumscribed,  taking  the  form  of  a 
fibroid  tumor  or  a  cyst,  usually  colloid,  or  a  circumscribed  adenoma,  it  is 
unnecessary  to  remove  an  entire  lobe  of  the  gland.  In  this  event  an  incision 
is  made  over  the  enlargement  in  such  a  manner  as  to  produce  as  little  deformity 
as  possible.  Then  the  capsule  of  the  gland  is  split,  care  being  taken  to 
grasp  portions  of  the  capsule  between  two  pairs  of  forceps  before  cutting 
it  in  order  to  prevent  hemorrhage.  "When  the  nodule  in  question  is  exposed 
a  point  of  cleavage  between  it  and  the  remaining  portion  of  the  gland  is 
sought  and  the  mass  is  readily  enucleated  either  with  the  finger,  a  Kocher's 
director  or  a  blunt  dissector.  In  case  of  troublesome  hemorrhage  tension  is 
made  upwards  upon  the  forceps  which  have  been  applied  to  the  capsule  and 
a  few  stitches  passed  through  the  walls  of  the  cavity  from  which  the  growth 
has  been  removed,  and  tied  with  just  sufficient  tension  to  overcome  the 
bleeding.  The  capsule  is  then  sutured  and  the  skin  is  sutured  over  it.  If 
the  cyst  is  of  large  size  the  whole  lobe  of  the  gland  should  be  thoroughly 
exposed. 


166  SURGERY  OF  THE  NECK 

If  the  precautions  which  have  been  mentioned  are  borne  in  mind  the 
operation  is  relatively  very  safe,  unless  it  is  done  during  a  condition  of 
severe  dyspnea,  which  may  occur  at  any  time  in  cases  in  which  there  is 
much  pressure  upon  the  trachea  from  an  acute  edema  of  the  growth.  In 
such  an  event  it  is  frequently  unsafe  to  anesthetize  the  patient  and  then  it  is 
best  to  cocainize  the  line  of  skin  incision  with  a  one  per  cent,  solution  of 
cocaine  and  to  infiltrate  the  deeper  layers  with  a  one-tenth  of  one  per 
cent,  solution  of  cocaine  in  a  normal  salt  solution.  The  pressure  is  almost 
always  due  to  an  enlargement  of  the  middle  lobe,  and  it  is  consequently 
wise  to  make  a  horseshoe-shaped  incision,  through  the  skin  with  the  con- 
vexity downward,  to  grasp  the  vessels  rapidly  between  two  pairs  of  forceps, 
to  cut  them,  and  as  soon  as  the  middle  lobe  is  exposed,  to  insert  into  it  sharp- 
pointed  retractors  with  at  least  four  teeth,  the  ordinary  catspaw  variety 
being  the  most  useful,  and  with  these  to  lift  the  lobe  upwards  and  thus  dis- 
lodge it  from  its  location  behind  the  sternum  where  it  causes  the  pressure 
which  gives  rise  to  the  condition  of  dyspnea.  After  this  lobe  has  once  been 
dislodged  the  dyspnea  ceases  and  the  remaining  steps  of  the  operation  may 
be  completed  without  difficulty  and  without  danger  to  the  patient.  We  have 
found  it  necessary  to  operate  upon  patients  in  this  condition  in  the  sitting 
posture,  as  in  the  recumbent  position  they  were  entirely  unable  to  breathe. 

TUBERCULOUS  GLANDS  OF  THE  NECK 

Pathogenesis.  In  the  treatment  of  tuberculous  glands  of  the  neck  the 
first  consideration  must  be  the  removal  of  tuberculous  material  from  the  body 
in  order  to  prevent  further  infection.  The  glands  which  are  first  infected 
have  progressed  furthest  in  the  changes  which  are  due  to  the  presence  of 
tubercle  bacilli.  In  the  earlier  stages  the  gland  is  hypertrophied  and  contains 
numerous  tuberculous  foci  which  may  be  separated  by  normal  gland  tissue, 
or  a  number  of  these  foci  may  have  developed  so  closely  together  that  thej^ 
will  form  one  nodule.  Presently  more  and  more  of  these  foci  will  develop 
in  close  proximity  and  then  the  nutrition  of  this  portion  of  the  gland  will 
become  impaired  and  caseous  degeneration  will  take  place.  It  is  important 
to  bear  this  in  mind  because  in  this  way  one  can  recognize  the  direction  from 
which  the  infection  has  taken  place,  which  in  turn  will  afi:'ect  the  plan  of 
treatment.  The  source  of  infection  is  most  commonly  found  in  tuberculous 
foci  which  have  developed  in  the  tonsils.  This  infection  may  occur  from 
particles  of  food  containing  tubercle  bacilli  becoming  lodged  upon  the  surfaces 
and  within  crypts  of  the  tonsils ;  from  particles  of  sputa  containing  bacilli 
lodged  in  the  same  manner;  or  from  mucus  descending  from  the  posterior 
nares  containing  bacilli  which  have  been  lodged  in  this  mucus  from  dust  in 
the  air. 

Patients  suffering  from  tuberculous  glands  of  the  neck  have  usually  lived 
in  surroundings  in  which  the  dust  was  likely  to  contain  tubercle  bacilli  owing 
to  the  careless  disposition  of  sputum  of  patients  suffering  from  tuberculosis  of 
the  lungs,  or  they  have  been  in  the  habit  of  drinking  unsterilized  milk. 

Causative  influences.  In  our  own  practice  children  living  under  unhy- 
gienic surroundings  in  houses  containing  tuberculous  patients,  and  children 
coming  from  the  farms  where  they  live  to  a  very  large  extent  upon  uncooked 
milk,  are  the  two  classes  in  which  we  have  found  this  condition  most  com- 
monly. In  the  vast  majority  of  these  patients  we  have  been  able  to  determine 
the  presence  of  tuberculous  foci  in  the  tonsils  in  children,  or  in  the  apices 
of  the  lungs  in  adults.  These  facts  are  of  very  great  importance  because 
if  they  are  not  recognized  our  treatment  is  not  likely  to  benefit  the  patient 


SURGERY  OF  THE  NECK  .       167 

greatly,  as  a  reinfection  is  almost  certain  to  occur  as  soon  as  the  patient  is 
exposed  to  the  influences  which  first  gave  rise  to  the  disease. 

Clinical  instance.  A  young  lady  eighteen  years  of  age,  living  at  home  and  taking  care  of 
her  three  younger  sisters,  gives  the  following  history,  which  is  typical  of  these  cases  in  many 
respects,  and  may  well  serve  to  illustrate  the  etiology  and  diagnosis  of  this  disease. 

Her  mother  died  at  the  age  of  forty-two  from  tuberculosis  of  the  lungs,  when  our  patient 
was  but  twelve  years  of  age.  The  father  is  in  excellent  health;  her  three  younger  sisters  are 
also  in  perfect  health.  The  patient  suffered  from  whooping-cough,  measles  and  scarlet  fever 
while  still  young,  having  the  last  named  disease  at  the  age  of  six.  After  this  time  she  suffered 
frequently  from  a  mild  form  of  tonsilitis,  the  tonsils  remaining  greatly  enlarged  and  swelling  to 
such  an  extent  as  to  almost  close  the  pharynx,  making  it  difficult  to  breathe  through  the  nose 
whenever  they  were  at  all  congested.  Shortly  after  her  mother  died  she  first  noticed  a  small 
swelling  beneath  her  left  ear.  This  varied  in  size,  but  was  always  larger  when  she  suffered 
from  colds.  Several  months  ago  her  general  condition  became  impaired  arid  she  became  quite 
anemic.  At  about  the  same  time  she  noticed  several  swellings  beneath  the  first  one  and  a 
further  swelling  beneath  the  angle  of  the  jaw  on  the  left  side.  These  have  increased  in  size 
slowly  but  constantly,  the  latest  one  being  located  directly  above  the  clavicle. 

The  patient  is  fairly  well  nourished;  her  appetite  fair;  her  tongue  is  clean;  the  bowels  are 
fairly  regular;  the  temperature  is  normal;  pulse  100,  full  and  strong;  her  heart,  lungs  and 
kidneys  are  normal.  She  is  quite  markedly  anemic.  There  is  a  series  of  swellings  extending 
from  a  point  beneath  the  mastoid  process  along  the  anterior  border  of  the  sterno-cleido-mastoid 
muscle  down  to  the  clavicle;  several  nodules  beneath  the  angle  of  the  jaw  on  the  left  side;  also 
a  deep  swelling  apparently  underneath  the  sterno-cleido-mastoid  muscle.  None  of  these  swellings 
fluctuate.  The  examination  of  the  blood  shows  the  amount  of  hemoglobin  decreased,  but  other- 
wise it  is  normal. 

This  history  is  a  typical  one  in  cases  of  tuberculosis  of  the  cervical  glands. 
Scarlet  fever  and  measles  are  so  common  in  this  community  that  it  would 
be  difficult  to  prove  a  connection  between  these  conditions  and  tubercular 
glands  of  the  neck,  but  in  a  majority  of  these  cases  one  will  find  that  a 
certain  amount  of  infection  remains  in  the  tonsils,  which  in  turn  undoubtedly 
makes  the  tuberculous  infection  of  the  lymphatic  glands  of  the  neck  more 
likely. 

In  this  case  the  oldest  child  was  associated  with  her  mother  during  the 
latter 's  sickness  from  pulmonary  tuberculosis,  the  younger  children  being 
cared  for  by  relatives.  This  would  account  for  the  infection  of  the  oldest, 
and  for  the  freedom  from  infection  in  the  three  younger  daughters.  The 
slowness  in  the  progress  of  the  disease  may  be  accounted  for  by  the  fact  that 
the  child  was  naturally  strong  and  healthy  and  that  she  has  always  lived 
under  good  hygienic  surroundings,  with  the  exception  of  the  time  she  was 
with  her  sick  mother.  The  same  conditions  account  for  the  good  health  of 
her  younger  sisters. 

The  history  contains  one  feature  which  is  quite  common  in  these  cases, 
viz.,  that  relating  to  the  variation  in  the  size  of  the  glands  during  the  early 
part  of  the  infection;  the  increase  in  size  corresponding  to  the  time  when 
the  patient  was  suffering  from  cold — in  other  words,  during  the  acute  rein 
fection.  Had  this  patient  been  subjected  to  proper  treatment  at  this  time 
it  is  quite  possible  that  the  existing  swelling  in  the  glands  would  have  disap- 
peared entirely,  but  one  cannot  make  a  positive  statement  regarding  this, 
as  the  existing  initial  infection  is  much  more  severe  in  some  cases  than  in 
others. 

For  four  months  this  patient  has  been  treated  very  properly  by  means  of 
internal  medication.  She  has  been  given  tonics,  her  work  in  school  has  been 
interrupted,  and  she  has  been  out-of-doors  a  great  share  of  the  time.  Her 
household  cares  have  been  reduced.  She  has  also  received  some  form  of 
creosote,  which  is  supposed  to  have  a  direct  effect  upon  the  tuberculous 
infection.  Her  general  health  has  been  greatly  improved  in  the  meantime, 
but  there  has  been  a  slight  increase  in  the  size  of  the  swellings,  although 
this  has  been  very  slow. 


168  SURGERY  OF  THE  NECK 

There  are  two  reasons  why  in  this  ease  this  form  of  treatment  has  not 
resulted  in  a  reduction  in  the  size  of  these  swellings,  or  possibly  a  cure. 
In  the  first  place  the  primary  source  of  infection  is  in  the  tubercular  foci 
contained  in  her  greatly  enlarged  tonsils.  Secondly,  the  degree  of  infection 
in  the  lymphatic  glands  of  her  neck  has  already  advanced  to  such  an  extent 
that  its  absorption  is  not  to  be  expected.  It  will  consequently  become  neces- 
sary for  us  to  relieve  her  by  means  of  operative  treatment. 

General  treatment.  All  of  these  steps  may  be  considered  as  important 
features  in  removing  the  cause.  The  second  element  consists  in  building  up 
the  patient's  resistance,  which  is  accomplished  mainly  by  providing  hygienic 
surroundings,  an  abundance  of  fresh  air,  absence  from  dampness;  by  living  a 
considerable  distance  above  the  ground ;  by  exposure  of  the  air  in  the  living 
and  sleeping  room  to  sunlight  •,  by  selecting  a  proper  dwelling ;  and  by  dis- 
pensing with  eurtains  that  obstruct  the  sunlight;  and  above  all  by  selecting 
proper  food. 

It  is  important  not  to  tell  these  patients  in  a  general  way  that  they  must 
select  an  abundance  of  wholesome  food,  but  they  must  be  instructed  in  writing 
just  Avhat  to  eat,  how  much  to  eat  and  when  to  eat.  All  of  this  must  also 
be  insisted  upon  after  an  operation  has  been  performed.  We  would  prefer 
to  entrust  any  early  case  of  tubercular  cervical  lymph  nodes  to  a  surgeon 
of  very  slight  technical  skill,  if  he  thoroughly  carried  out  the  above  plan,  than 
to  a  surgeon  of  the  highest  possible  skill  who  simply  removed  the  diseased 
glands  and  paid  no  attention  to  the  features  just  discussed,  because  in  the 
former  instance  a  very  large  proportion  of  these  cases  would  recover  perma- 
nently without  being  compelled  to  undergo  any  operation,  while  of  those 
operated  there  would  probably  be  no  mortality ;  whereas  in  the  second  instance 
there  would  probably  be  very  beautiful  immediate  operative  results,  to  be 
followed  by  a  large  proportion  of  recurrences  and  a  very  large  proportion 
of  ultimate  deaths  due  to  pulmonary  tuberculosis. 

The  surgeon  who  simply  removes  the  existing  tubercular  glands  in  patients 
coming  under  his  care,  even  though  this  be  done  with  the  greatest  possible 
skill,  is  a  menace  to  the  community. 

The  exposure  of  the  neck  in  these  patients  to  the  X-ray,  after  removing 
tonsils  and  adenoids  and  carrying  out  the  other  steps  indicated  above,  has 
been  found  very  effective  by  many  surgeons  while  others  frown  upon  this  plan 
of  treatment.    It  has  seemed  very  beneficial  to  us. 

Before  proceeding  to  the  description  of  the  operative  treatment  of  tuber- 
culous cervical  lymph  nodes  we  should  emphasize  the  fact  that  in  a  vast 
majority  of  these  cases  no  operation  will  ever  become  necessary  if  the  patient 
receives  reasonably  intelligent  treatment  after  the  first  symptoms  appear. 

This  treatment  must  contain  three  very  distinct  elements.  In  the  first 
place  the  cause  must  be  removed.  If  the  patient  is  surrounded  by  persons 
suft'ering  from  pulmonary  tuberculosis  who  are  the  producers  of  the  tubercle 
bacilli  which  infect  the  patient,  then  such  should  be  placed  in  a  sanitarium 
where  they  will  be  taught  how  to  protect  their  associates  by  the  thoroughly 
established  methods  which  have  been  successfully  tried  in  such  institutions. 
They  should  be  taught  the  dangers  of  coughing  into  the  air,  of  expectorating 
except  into  a  receptacle  which  can  be  boiled,  or  into  a  paper  napkin  which 
can  be  burned.  Moreover,  they  should  be  taught  how  to  sterilize  milk  and 
meats.  If  the  dwelling  is  unhygienic  this  should  be  changed.  The  local  foci 
in  the  tonsils,  and  the  adenoids,  should  be  carefully  removed.  The  patient 
should  be  given  breathing  exercises  consisting  of  inhaling  to  the  fullest  extent 
and  exhaling  by  blowing  through  a  small  opening  between  the  lips. 


SUROEEY  OF  THE  NECK  169 

Technique  of  operation.    In  this  operation  we  must  consider : — 

1st.  The  deep  jugular  vein,  as  its  injury  might  result  in  the  introduction 
of  air  into  the  circulation,  causing  air-embolism  and  death. 

2d.     The  carotid  arteries  and  the  pneumogastric  nerve. 

3d.  Some  of  the  more  important  branches  of  the  spinal  accessory  nerve 
must  be  preserved,  because  their  injury  results  in  marked  deformity,  due  to 
paralysis  of  the  trapezius  muscle,  and  consequent  discomfort  to  the  patient. 

4th.  The  scar  should  be  so  placed  as  to  cause  in  itself  as  little  deformity 
as  possible. 

An  incision,  therefore,  is  made  along  the  anterior  edge  of  the  sterno-cleido- 
mastoid  muscle,  from  the  mastoid  process  down  to  the  clavicle.  The  superficial 
fascia  is  carefully  dissected  back  on  each  side  of  this  incision.  The  first 
incision  severs  the  external  jugular  vein,  which  should  at  once  be  caught  and 
ligated  on  each  side  of  the  division,  or  it  is  still  better  to  grasp  the  vein  between 
two  pairs  of  forceps  and  to  cut  it  after  it  has  been  thus  caught,  and  then 
ligate  at  once.  The  edges  of  the  wound  should  now  be  carefully  retracted 
and  a  dissection  begun  at  the  lower  end  of  the  incision.  This  should  be  carried 
on  carefully  until  the  sheath  of  the  deep  jugular  vein  is  reached,  which  may 
be  followed  upwards  until  the  entire  vein  has  been  laid  bare  from  the  clavicle 
to  the  angle  of  the  jaw.  The  lymphatic  glands  are  closely  adherent  to  the 
sheath  of  the  vein,  but  with  the  vein  plainlj'^  in  view  there  is  no  danger  of 
injuring  it  if  the  dissection  is  pursued  carefully. 

About  an  inch  below  the  angle  of  the  jaw  we  find  several  enlarged  glands. 

This  is  at  the  point  at  which  the  facial  vein  enters  the  deep  jugular.  It 
is  a  favorite  location  for  a  tuberculous  lymphatic  gland.  Great  care  must  be 
taken  in  dissecting  out  this  gland  as  one  is  in  danger  of  injuring  the  facial 
or  the  deep  jugular  vein,  or  both.  In  this  instance  it  is  possible  to  secure  a 
sufficient  amount  of  space  without  making  a  transverse  incision,  but  occa- 
sionally it  is  necessary  to  carry  the  wound  some  distance  below  the  lower 
jaw,  and  parallel  with  it,  in  order  to  remove  all  the  submaxillary  glands.  It 
is  not  unusual  to  find  the  submaxillary  lymphatic  gland  infected  with  tubercu- 
losis, necessitating  its  removal.  If  this  is  necessary  it  is  best  to  grasp  the 
facial  artery  and  vein  between  two  pairs  of  hemostatic  forceps  and  cut  between 
these  just  below  the  point  where  they  enter  the  submaxillary  salivary  gland, 
because  in  this  way  one  can  prevent  some  hemorrhage  and  the  clouding  of 
the  field  of  operation.  To  the  outer  side  and  behind  the  deep  jugular  vein 
the  lymphatic  glands  are  also  enlarged  and  we  carry  our  dissection  upwards 
behind  the  edge  of  the  stemo-cleido-mastoid  muscle.  About  half  the  distance 
between  the  lower  and  the  upper  attachment  of  the  sterno-cleido-mastoid 
muscle,  or  at  a  point  at  which  the  trapezius  muscle  approaches  the  former, 
several  branches  of  the  spinal  accessory  nerve  will  be  encountered.  It  is  impor- 
tant to  preserve  these  as  their  destruction  will  result  in  a  drooping  of  the 
shoulder  and  an  atrophy  of  the  muscles  of  the  lower  part  of  the  neck.  In 
making  the  dissection  from  below  upwards  the  superficial  cervical  nerve  will 
be  encountered  passing  transversely  across  the  sterno-cleido-mastoid  muscle 
about  its  middle.  A  little  above  this  point  the  spinal  accessory  nerve  passes 
out  of  the  sterno-cleido-mastoid  muscle  and  thence  backward  and  downward 
into  the  trapezius  muscle.  The  superficial  cervical  nerve  being  larger  and  more 
superficial  serves  as  a  guide  to  the  more  important  spinal  accessory.  The  latter 
should  be  carefully  dissected  out  to  its  insertion  in  order  to  avoid  an  accidental 
injury. 

We  have  now  disposed  of  all  of  the  enlarged  glands  with  the  exception 
of  those  underneath  the  upper  portion  of  the  sterno-cleido-mastoid  muscle. 
These  may  be  approached  by  making  a  transverse  incision  through  the  sterno- 
cleido-mastoid  muscle,  by  splitting  the  latter  longitudinally,  or,  better  still, 
by  dissecting  the  muscle  entirely  free  and  drawing  it  out  of  the  field  of  opera- 


170 


SURGERY  OF  THE  NECK 


tion  by  means  of  retractors.  The  last  of  the  three  methods  mentioned  will 
be  followed  here  as  it  does  the  slightest  amount  of  injury  to  this  important 
muscle,  while  the  other  methods  are  undoubtedly  both  harmful  and  unneces- 
sary. 

All  the  infected  glands  have  now  been  carefully  removed.  It  is  our  prac- 
tice to  apply  strong  compound  tincture  of  iodine  to  all  the  raw  surfaces  with 
the  expectation  of  destroying  thereby  any  bacilli  still  remaining  in  these  tissues, 
and  also  with  the  idea  of  stimulating  the  tissues  to  increased  healing.  Other 
surgeons  use  different  antiseptics  for  the  same  purpose,  and  still  others  use 
none  at  all,  and  apparently  all  are  equally  successful. 

It  is  wise  to  supply  some  means  of  escape  for  the  serum,  which,  during 
the  first  twenty-four  hours,  will  accumulate  from  the  large  raw  surfaces.  In 
order  that  the  flaps  may  not  be  separated  by  the  accumulating  serum,  after 
once  uniting,  we  will  insert  a  small  drain  in  the  lower  angle  of  the  wound, 
and  then  will  unite  the  edges  of  the  wound,  using  the  utmost  care  to  secure 
a  most  perfect  coaptation,  because  in  this  way  we  will  be  able  to  avoid  as 
much  as  possible  the  formation  of  a  disfiguring  scar. 

We  are  in  the  habit  of  uniting  the  fascia  with  a  separate  row  of  catgut 
sutures  in  order  to  avoid  a  depression  of  the  scar. 

Removal  of  tonsils  and  adenoids.  The  most  important  part  of  the  operation 
still  remains,  for  were  we  to  leave  this  patient  in  her  present  condition  she 


Bovine  Tttberculosis  of  the  Glands  of  Both  Sides  of  the  Neck  in  a  Child  Three  Years 
OF  Age.     Treated  by  Surgical  Excision  in  Two  Stages. 


would  be  virtually  worse  off  than  when  we  started  the  operation,  as  in  remov- 
ing the  diseased  lymphatic  glands  we  have  undoubtedly  removed  many  normal 
ones  which  might  serve  to  protect  the  patient  against  further  invasions  through 
the  same  source  of  infection — which  still  remains — in  other  words,  we  have  not 
only  relieved  our  patient  of  her  diseased  lymphatic  glands,  but  also  of  many 
lymphatic  glands  which  if  left  in  place  would  serve  to  protect  her.  We  must, 
therefore,  remove  the  cause  of  infection  in  this  case,  which  exists  in  the  tuber- 
culous foci  in  her  tonsils,  and  in  the  adenoids  in  the  post-nasal  space.  We  there- 
fore place  the  patient  in  the  inverted  position  and  permit  her  head  to  hang 
backward  over  the  end  of  the  table.  We  then  insert  a  gag  between  her  teeth 
to  keep  the  mouth  open,  and  then  remove  both  tonsils  ;  and  by  means  of  a  broad, 
flat,  post-nasal  curette  we  curette  away  the  adenoids,  protecting  the  uvula 
and  soft  palate  by  inserting  the  left  index  finger.     In  order  to  complete  the 


'  SURGEKY  OF  THE  NECK  171 

removal  of  these  adenoids  we  further  insert  a  small,  ordinary,  moderately 
blunt  curette  through  the  nostril,  and,  guiding  the  spoon  with  the  left  index 
finger  in  the  pharynx,  curette  away  all  of  the  remaining  granulations.  This 
step  is  taken  first  through  one  nostril  and  then  through  the  other  until  the 
pharynx  is  perfectly  free  from  adenoids.  At  the  same  time  we  examine  the 
patient's  mouth  and  if  she  has  any  decayed  teeth  to  act  as  a  source  of  infection 
they  will  be  removed. 

After-treatment  important.  In  these  cases  it  is  especially  important  that 
the  after-treatment  be  carefully  supervised  by  the  surgeon.  One  of  the  most 
important  features  of  this  after-treatment  consists  in  instructing  the  patient 
to  take  breathing  exercises  systematically.  It  is  our  practice  to  have  these 
patients  inhale  through  the  nose  with  closed  lips,  filling  the  chest  completely, 
and  then  exhale  while  they  resist  with  the  lips.  The  most  convenient  way  of 
accomplishing  the  latter  step  is  by  placing  between  the  lips  a  small  tube  about 
two  millimeters  in  diameter.  This  exercise  should  be  practised  at  least  twenty 
times  in  the  morning  and  again  as  many  times  in  the  evening. 

The  hygienic  surroundings  of  the  patient  should  be  favorable.  The  living 
and  sleeping  room  should  be  high,  dry  and  sunny.  The  food  should  be  nourish- 
ing and  simple  and  the  patient  should  have  an  abundance  of  outdoor  exercise. 
Tonics  and  anti-tubercular  remedies  should  be  given  systematically  until  full 
recovery,  and  a  patient's  habits  should  be  so  formed  that  it  becomes  natural 
for  him  to  live  hygienically. 

It  is  far  more  important  that  these  last  mentioned  directions  be  carried  out 
than  that  the  tuberculous  glands  be  removed,  because  if  these  hygienic  meas- 
ures are  carefully  followed  the  patient  will  usually  live  much  longer  and  be  in 
much  better  health,  even  though  the  glands  be  not  removed,  than  would  obtain 
if  the  glands  were  removed  after  the  most  perfect  method  and  no  attention  paid 
to  the  dangers  by  reinfection.  The  plan  which  must  consequently  result  in 
restoring  these  patients  permanently  to  good  health,  and  to  the  lengthening 
of  their  lives  to  the  greatest  possible  degree,  consist  in  removing  all  of  the 
infected  glands,  as  well  as  the  primary  foci  of  infection  whenever  this  is 
possible ;  in  improving  the  hygienic  conditions  and  the  food ;  and  in  adminis- 
tering tonics  and  anti-tubercular  remedies ;  all  of  which  can  only  be  accom- 
plished by  impressing  the  patient  with  the  importance  of  the  conditions  and 
the  consequences. 

The  principles  laid  down  above  regarding  the  operation  for  removal  and 
the  after-treatment  of  tuberculous  glands  in  the  neck  will  apply  to  tubercular 
glands  in  general  without  regard  to  the  location  in  the  body.  It  is  character- 
istic for  these  glands  to  be  adherent  to  the  veins  wherever  they  may  occur, 
because  the  lymphatic  glands  which  are  most  likely  to  be  infected  by  tubercu- 
losis are  all  located  in  close  proximity  to  the  larger  veins  of  the  body. 

General  prognosis.  If  the  tuberculous  glands  of  the  neck  which  do  not  dis- 
appear under  internal  and  hygienic  treatment,  and  after  the  removal  of  the 
focus  from  which  the  original  infection  has  taken  place,  are  removed,  and  the 
internal  and  hygienic  after-treatment  which  has  been  outlined  here  has  been 
followed,  then  the  prognosis  in  these  cases  is  good  both  as  regards  immediate 
and  permanent  results.  If  broken  down  tuberculous  glands  of  the  neck  are  not 
removed  the  degeneration  may  proceed  to  calcification  of  the  caseous  portion 
of  the  gland  and  the  patient  may  still  recover,  or  adhesions  may  take  place 
between  the  gland  and  surrounding  structures,  and  the  accumulation  of  tuber- 
culous material  may  result  in  a  sufficient  amount  of  pressure-necrosis  of  the 
overlying  tissues  to  cause  a  perforation  through  the  skin  and  spontaneous 
drainage.  This  may  continue  for  a  considerable  time,  or  may  be  relieved  by 
means  of  an  operation.    In  the  former  case  the  patient  remains  ill  for  a  long 


172  SimaERY  OF  THE  NECK 

period,  and  if  a  spontaneous  cure  results  it  will  be  accompanied  by  a  consid- 
erable amount  of  deformity. 

Again,  the  infection  may  progress  from  one  set  of  glands  to  another  until 
all  of  the  cervical  lymphatics  have  become  involved.  Then  the  space  occupied 
by  the  lymphatics  extending  from  the  neck  into  the  axilla  behind  the  clavicle 
may  be  affected  and  there  may  be  a  tuberculous  infection  of  the  axillary 
lymphatic  glands ;  or,  again,  the  infection  may  extend  along  the  median  line 
into  the  cavity  of  the  chest.  Each  of  these  conditions  is,  of  course,  much  more 
serious  than  the  original  infection;  consequently  the  danger  should  be  inter- 
rupted before  it  has  progressed  to  one  or  the  other  of  these  unfortunate  results. 

During  the  past  few  years  so  much  progress  has  been  made  in  the  hygienic 
and  dietetic  treatment  of  pulmonary  tuberculosis  that  all  that  has  been  said 
above  should  be  supplemented  by  directing  the  patient  to  live  precisely  as  he 
would  be  directed  to  were  he  suffering  from  incipient  pulmonary  consumption. 
He  should  live,  and  especially  sleep,  out-of-doors,  eat  an  abundance  of  eggs, 
beef  and  mutton  and  drink  at  least  two  quarts  of  milk  daily,  from  tuberculin- 
tested  cows,  or,  if  ordinary  milk  is  used,  sterilize  it  without  boiling.  A  steriliz- 
ing apparatus  may  be  improvised  in  the  poorest  kitchen  by  the  use  of  a  fruit 
jar  and  an  ordinary  kettle  in  which  a  cloth  has  been  placed  to  prevent  the 
heat  from  cracking  the  fruit  jar.  The  latter,  containing  the  milk,  should  of 
course  be  placed  in  the  water  in  the  kettle  before  very  much  heat  is  applied. 

The  water  should  boil  about  the  fruit  jar  at  least  twenty  minutes. 

The  patient  should  also  eat  an  abundance  of  cooked  vegetables,  cereals 
and  cooked  fruits,  with  bread  and  butter,  but  none  of  the  non-nutritious  condi- 
ments.   Alcohol  in  every  form  is  harmful  and  should  be  tabooed. 

Use  of  Beck's  bismuth  paste.  In  old  cases  that  have  suppurated  and  in 
which  there  are  resulting  sinuses  the  injection  of  a  sufficient  amount  of  Beck's 
bismuth  paste  every  two  to  six  days,  so  as  to  fill  the  sinus  without  over-distend- 
ing it,  and  closing  the  external  opening  with  a  gauze  plug,  will  speedily  dis- 
infect the  discharge  and  the  sinuses  will  usually  heal  in  a  short  time. 

The  tonsils  and  adenoids  must  of  course  be  removed  in  these  as  in  the  other 
cases,  to  prevent  reinfection. 

Later  it  is  advisable  to  excise  the  disfiguring  scars  marking  the  position  of 
the  sinuses,  and  to  close  the  defect  carefully  so  as  to  reduce  the  deformity  to  a 
minimum.  It  is  best  not  to  perform  this  secondary  operation  until  after  the 
sinus  has  been  healed  for  at  least  one  year,  for  fear  of  having  the  edges  of  the 
wound  break  down  after  suturing,  leaving  an  unsightly  scar. 

HODGKIN'S  DISEASE 

The  Ij^mphatic  glands  of  the  neck  frequently  undergo  a  form  of  enlarge- 
ment and  degeneration  which  is  probably  also  infectious  in  its  character,  but 
in  which  we  are  not  able  at  the  present  time  to  determine  the  nature  of  the 
infection.  Bunting  and  Yates  have  isolated  from  these  glands  a  diphtheroid 
bacillus,  pleomorphic  in  type,  which  they  hold  is  the  causative  factor  in  Hodg- 
kin's  disease.  This  has  not  been  generally  accepted  as  yet,  and  the  finding  of 
this,  or  an  organism  so  similar  to  it  that  they  are  scarcely  distinguishable,  in 
lymph  glands  from  patients  suffering  from  a  variety  of  diseases  and  in  glands 
from  normal  persons,  has  given  rise  to  the  belief  that  the  cause  of  Hodgkin's 
disease  is  not  yet  known.  Nor  has  vaccine  or  serum  therapy,  using  the 
Bunting-Yates  organism  in  the  production  of  these  vaccines  and  serums,  proven 
satisfactory. 

The  condition  is  rarely  entirely  confined  to  the  region  of  the  neck,  the 
lymphatic  glands  in  other  portions  of  the  body  being  enlarged  also.  The  glands 
are  harder  and  usually  more  closely  grouped  than  in  tuberculosis.    The  patient 


SURGERY  OF  THE  NECK  173 

is  anemic  or  cachectic  in  appearance.  Upon  removal  of  a  gland  it  is  found  to 
contain  a  uniform  structure  in  which  there  are  no  circumscribed  tubercles  or 
foci  of  caseation.  These  glands  contain  an  abundance  of  connective  tissue  and 
the  spherical  cells  of  the  normal  lymph  gland  will  be  seen  to  have  lost  their 
characteristic  appearance. 

The  removal  of  the  enlarged  lymph  glands  in  Hodgkin's  disease  does  not 
benefit  the  patient  except  when  their  presence  interferes  with  respiration  by 
pressure  upon  the  trachea.  In  a  considerable  number  of  these  cases  there  has 
been  a  rapid  disappearance  of  the  glands  under  treatment  with  the  X-ray,  but 
it  will  be  necessary  to  follow  them  further  before  anything  positive  can  be  said 
on  this  subject. 

Hygiene  and  diet  should  be  carefully  regulated.  The  patient  should  also 
receive  tonics  and  from  one-half  to  two  grains  of  sodium  arsenate  given  hypo- 
dermically  each  day  in  a  five  per  cent,  solution  of  distilled  water.  This  seems 
to  be  beneficial. 

LYMPHATIC  LEUKEMIA 

Enlargement  of  the  cervical  lymphatics  as  a  result  of  lymphatic  leukemia 
may  be  differentiated  from  Hodgkin's  disease  and  from  tuberculous  adenitis 
by  the  marked  increase  in  the  leucocytes  in  the  blood.  The  treatment  of 
lymphatic  leukemia  is  not  surgical. 

LYMPHO-SARCOMA  OF  THE  NECK 

This  disease  is  differentiated  from  the  other  conditions  which  are  similar 
in  appearance,  and  that  have  just  been  described : — 

1st.     By  the  absence  of  a  history  of  tubercular  infection. 

2d.  By  the  fact  that  the  surrounding  tissues  are  invaded  very  soon  after 
the  beginning  of  the  disease. 

3d.     By  the  rapidity  of  its  development ;  and 

4th.     By  the  early  appearance  of  cachexia. 

The  excision  of  a  sarcoma  of  the  neck  is  the  only  treatment  which  has 
heretofore  seemed  to  promise  anything  for  the  patient.  From  the  anatomical 
conditions  present  in  this  region  an  extensive  removal  is,  of  course,  not  pos- 
sible, and  consequently  these  cases,  with  very  few  exceptions,  have  been 
hopeless ;  and  still  there  are  undoubtedly  a  few  that  have  recovered  per- 
manently. The  after-treatment  with  the  X-ray  seems  to  be  of  great  import- 
ance. We  have  seen  severe  cases  in  which  recurrent  nodules  have  disappeared 
permanently  after  use  of  the  X-ray. 

CARCINOMA  OF  THE  LYMPHATIC  GLANDS  OF  THE  NECK 

This  is  always  secondary  to  the  presence  of  carcinoma  of  some  portion  of 
the  face,  pharynx,  parotid  gland,  or  tonsil,  which  will  differentiate  it  from  the 
conditions  which  have  just  been  described.  Thorough  surgical  removal  is  the 
only  treatment  that  promises  anything,  with  the  possible  exception  of  treat- 
ment by  the  X-ray.    The  condition  is,  therefore,  almost  hopeless. 

In  operating  every  structure,  with  the  exception  of  the  pneumogastric 
nerve,  that  may  be  even  slightly  involved  must  be  excised.  "We  prefer  to  make 
the  excision  with  the  cautery  in  order  to  prevent  reinfection  with  the  car- 
cinoma tissue  and  toxin. 

These  cases  should  all  receive  vigoroiis  after-treatment  with  the  X-ray. 


174 


SURGERY  OF  THE  NECK 
DIFFUSE  DISSECTING  LIPOMA  OF  THE  NECK 


This  usually  begins  in  the  median  line  opposite  the  spinous  processes  of 
the  cervical  vertebrse,  and  becomes  wider  in  every  direction  until  it  covers 
the  entire  posterior  surface  of  the  neck,  giving  the  appearance  from  the  rear 
of  an  enormous  collar  of  fat.  Laterally  it  advances  around  the  neck  until 
its  two  wings  meet,  unless  an  excision  is  made  before  this  occurs.  The 
tumor  is  lobulated,  is  from  1  to  5  cm.  thick,  and  it  has  the  peculiar  quality 
of  following  the  connective  tissue  in  every  direction  by  dissecting  its  way 
between  the  other  structures  and  apparently  consuming  the  connective  tissue 


Large  Sarcoma  of  the  Neck — Inoperable. 

on  its  way,  hence  the  name  of  dissecting  lipoma.  Its  lobules  will  insinuate 
themselves  between  the  muscle  fibres  of  the  neck,  between  the  lobules  of  the 
parotid  and  thyroid  glands  and,  in  fact,  between  all  of  the  structures  which 
contain  connective  tissue. 

It  causes  much  distress  from  its  weight  and  from  pressure,  and  is  extremely 
unsightly.  The  patients  acquire  an  appearance  which  reminds  one  of  the 
cachexia  in  malignant  disease,  although  milder  in  form. 

As  soon  as  the  diagnosis  has  been  made  the  growth  should  be  excised  by 
means  of  a  most  painstaking,  exact  dissection,  because  if  any  lobules  remain 
a  recurrence  is  to  be  expected.  In  severe  cases  it  is  best  to  remove  one-half 
of  the  tumor  first  in  order  to  enable  the  patient  to  lie  down  with  some  degree 
of  comfort.     After  the  one  side  has  healed  fully  the  other  may  be  operated. 

These  surfaces  are  so  large  that  drainage  is  indicated,  otherwise  serum 


SURGERY  OF  THE  NECK  175 

is  likely  to  accumulate  under  the  large  flap  and  healing  will  therefore  be 
retarded.  The  drainage  may  be  removed  on  the  second  or  third  day  after 
the  operation. 

SEPTIC  INFECTION  OF  DEEP  TISSUES  IN  THE  NECK 

Quite  frequently  in  infants,  and  occasionally  in  adults,  there  is  a  septic 
infection  of  the  deep  tissues  of  the  neck  resulting  from  an  infection  of  the 
tonsil  or  some  portion  of  the  pharynx.  The  condition  is  violent  in  its  onset  and 
there  is  a  severely  indurated,  extensive  swelling  which  usually  begins  in  the 
upper  portion  of  the  neck  and  extends  downward.  The  induration  is  often  so 
severe  that  fluctuation  cannot  be  determined.  Pus,  however,  is  always  to  be 
found  in  the  deeper  tissues  and  its  removal  by  means  of  an  incision,  and  the 
subsequent  application  of  drainage  and  a  moist  antiseptic  dressing,  results  in 
a  rapid  recovery.  The  incision  should  be  made  carefully,  because  there  is  some- 
times a  displacement  of  the  anatomical  structures,  and  unless  care  is  taken 
these  are  likely  to  be  injured  during  the  operation. 

After  the  incision  has  been  made  through  the  skin  and  superficial  fascia 
it  is  often  best  to  separate  the  deep  tissues  bluntly  until  the  small  abscess  is 
reached,  rather  than  to  run  the  risk  of  injuring  important  parts,  especially  the 
deep  jugular  vein. 

LIGNOUS  INFILTRATION  OF  THE  NECK 

Lately  a  condition  has  been  classified  separately  from  other  extensive  infec- 
tions of  the  neck  because  of  the  extreme  board-like  hardness  of  the  tissues 
incident.  The  affection  progresses  rather  slowly  but  causes  profound  distress 
because  of  the  fact  that  the  tissues  are  quite  unyielding,  having  much  the 
appearance  of  infiltrating  skin  cancer — cancer  en  cuirasse. 

The  tissues  cut  like  cartilage  and  although  they  are  evidently  filled  with 
serum  and  with  leucocytes  the  surfaces  do  not  secrete  fluid  like  that  found 
upon  incising  skin  in  the  presence  of  ordinary  edema. 

The  tissues  should  be  freely  incised  and  the  deep  structures  freely  sepa- 
rated, much  the  same  as  heretofore  described.  Usually  a  focus  of  infection 
will  be  found  containing  a  few  drops  of  pus.  A  large,  hot,  moist  dressing 
consisting  of  two  parts  of  a  saturated  solution  of  boric  acid  and  one  part  of 
alcohol,  should  be  applied,  and  this  should  be  covered  with  an  impermeable 
substance  like  rubber  tissue,  held  in  place  by  a  roller  bandage.  The  prognosis 
is  favorable. 

TORTICOLLIS 

Space  will  permit  us  to  discuss  only  the  treatment  of  the  non-spasmodic 
form  of  torticollis,  which  depends  upon  a  shortening  of  the  sterno-cleido- 
mastoid  muscle. 

The  form  of  treatment  which  we  have  found  most  satisfactory  consists  in 
carefully  dissecting  out  the  sterno-cleido-mastoid  muscle,  or  what  is  left  of  it, 
together  with  the  cicatricial  tissue  which  may  compose  a  portion  of  the  muscle. 
Having  laid  bare  the  entire  muscle  it  is  split  in  halves  longitudinally  to  a 
point  within  an  inch  of  its  upper,  and  to  the  same  distance  with  regard  to  its 
lower  extremity.  Each  half  is  now  permitted  to  remain  attached  to  one  end, 
while  at  the  other  end  of  the  incision  through  the  muscle  it  is  cut  loose  so  that 
the  upper  attachment  carries  one-half  of  the  muscle  and  the  lower  attachment 
the  other  half.  The  head  is  now  turned  so  that  the  chin  reaches  the  shoulder 
of  the  side  on  which  the  short  muscle  exists^  in  order  to  determine  the  length 


176  SUHGERY  OF  THE  NECK 

desired,  and  the  two  ends  are  united  by  means  of  a  number  of  fine  catgut 
sutures.  After  the  head  is  turned  back  so  that  the  chin  is  opposite  the  sternum 
the  sutured  muscle  will  appear  considerably  relaxed.  It  will  give  the  impres- 
sion of  being  quite  a  little  too  long.  It  is  now  covered  with  the  superficial 
fascia  by  means  of  a  row  of  catgut  sutures  and  the  skin  is  sutured  over  all. 
This  leaves  the  diseased  side  entirely  without  tension.  The  muscle  usually  fills 
up  quite  rapidly,  and,  in  our  experience,  the  deformity  has  not  recurred  and 
the  function  has  been  very  satisfactory. 

Recently  we  have  made  an  incision  through  the  skin  along  the  upper  edge 
of  the  clavicle,  thoroughly  exposing  the  sternal  as  well  as  the  clavicular  attach- 
ment of  the  sterno-cleido-mastoid  muscle.  All  of  these  attachments  were  then 
severed  entirely  and  the  muscle  was  followed  upward  and  all  adhesions  were 
cut  which  seemed  in  any  way  to  interfere  with  an  absolutely  free  movement 
of  the  neck  and  head.  Then  two  small  drains  were  inserted  into  the  angles  of 
the  wound  which  was  then  sutured.  The  wound  in  the  neck  made  by  this 
operation  is  sometimes  very  deep,  as  unless  all  fibres  are  severed  the  operation 
must  fail. 

The  chief  advantage  in  this  operation  lies  in  the  fact  that  no  scar  is  pro- 
duced on  the  exposed  portion  of  the  neck.  The  disadvantage  rests  in  the  fact 
that  any  surgeon  who  has  not  witnessed  the  operation  at  the  hands  of  a  trained 
operator  is  not  likely  to  do  the  work  with  sufficient  thoroughness  to  give  a 
satisfactory  result. 

In  order  that  the  cut  ends  of  the  muscle  remain  apart,  it  is  necessary  in  these 
cases  to  apply  a  plaster  of  Paris  cast  with  the  head  in  an  exaggerated,  over- 
corrected  position.  With  the  patient  in  a  sitting  position  and  two  layers  of 
stockinette  applied  over  the  entire  head  and  upper  trunk,  with  holes  for  the 
arms,  plaster  of  Paris  bandages  are  applied  involving  the  entire  head,  chin, 
neck  and  chest  to  the  ensiform  process.  An  oval  opening  is  made  for  the  face 
from  the  superciliary  ridges  to  a  point  1  cm.  beneath  the  margin  of  the  lower 
lip.  This  cast  remains  in  position  for  three  to  four  weeks,  the  stitches  having 
been  removed  through  a  small  "window."  A  lighter  cast  or  special  brace 
should  then  be  applied  for  from  six  to  eight  weeks,  always  with  the  chin  turned 
to  the  side  of  the  deformity. 

SPASMODIC  TORTICOLLIS 

"Where  this  condition  is  absolutely  limited  to  spasmodic  contractions  of 
one  sterno-cleido-mastoid  muscle  it  is  proper  to  sever  the  spinal  accessory 
nerve  supplying  this  muscle,  but  in  every  case  that  has  come  under  our  care 
other  muscles  were  involved  and  consequently  such  an  operation  could  not 
relieve  it  satisfactorily.  In  severe  cases  the  condition  is,  however,  so  distressing 
that  resection  of  the  nerves  supplying  the  muscles  involved  would  be  justified, 
in  case  the  patient  would  be  willing  to  exchange  his  distress  for  the  resulting 
paralysis. 

TRACHEOTOMY 

Since  the  introduction  of  diphtheria  antitoxin  tracheotomy  is  performed 
almost  entirely  for  the  relief  of  obstruction  to  respiration  due  to  the  introduc- 
tion of  foreign  substances  into  the  larynx,  such  as  the  inspiration  of  kernels 
of  corn,  or  other  objects,  by  children  at  their  play,  or  the  forcing  down  of  the 
diphtheritic  membrane  in  the  attempt  to  introduce  an  intubation  tube.  It  is 
also  done  for  the  removal  of  foreign  substances  that  have  been  inspired,  and 
for  the  relief  of  obstruction  to  the  larynx  due  to  malignant  growths. 


SURGERY  OF  THE  NECK 


177 


By  the  courtesy  of  Dr.  George  E.  Brewer,  representing  the  preliminary  tracheotomy  with 
peritracheal  tamponade  preparatory  to  performing  laryngectomy. 


By  the  courtesy  of  Dr.  George  E.  Brewer,  representing  his  exposure   of  the  larynx  and 
thyroid  membrane  in  his  operation  of  laryngectomy. 


178  SURGERY  OF  THE  NECK 

Technique.  The  seat  of  the  operation  may  be  chosen  either  above  or  below 
the  isthmus  of  the  thyroid  gland,  or  should  the  patient  be  in  danger  of 
asphyxiation,  necessitating  a  very  rapid  operation,  the  incision  may  be  made 
directly  through  the  isthmus  of  the  thyroid  gland,  the  latter  having  previously 
been  grasped  between  two  pairs  of  hemostatic  forceps.  When  the  operation 
has  to  be  performed  with  extreme  rapidit}"  it  is  best  to  place  the  patient  in  the 
inverted  position  with  the  head  dependent  so  that  any  blood  w^hich  it  may  not 
be  possible  to  control  at  once  will  gravitate  away  from  the  opening  in  the 
trachea  and  will  not  be  inspired.  If  sharp  tenaculse  are  at  hand  it  is  wise  ta 
plunge  two  of  these  directly  through  the  skin  into  the  trachea  on  each  side  of 
the  median  line  and  then  to  make  an  incision  directly  into  the  trachea  with 
one  sweep  of  the  knife  and  to  hold  the  incision  open  hy  drawing  upon  the 
tenaculge  while  artificial  respiration  is  performed.  In  the  meantime  the  bleed- 
ing vessels  may  be  caught,  and  if  a  tracheotomy  tube  is  at  hand  it  may  be 
inserted.  This,  however,  is  not  at  all  an  attractive  operation  and  should  never 
be  done  except  in  the  presence  of  absolute  necessity.  If  the  operation  can  be 
done  leisurely  the  important  points  to  be  considered  are : 

1st.  To  control  the  hemorrhage  in  the  successive  steps  before  the  blood 
vessels  are  cut.  An  incision  should  be  made  in  the  median  line  and  each  blood 
vessel  caught  with  two  pairs  of  hemostatic  forceps  as  it  appears  in  the  wound, 
and  then  the  incision  should  be  continued.  In  this  manner  the  operation 
should  proceed  until  the  rings  of  the  trachea  are  plainly  in  view ;  then  all  the 
vessels  should  be  carefully  ligated  and  any  further  bleeding  points  caught  with 
forceps  and  tied,  and  then  the  two  tenaculae  should  be  passed  through  one  of 
the  tracheal  rings  to  either  side  of  the  median  line  and  the  trachea  incised 
longitudinally,  one,  two  or  three  cartilaginous  rings  being  cut  transversely. 

2nd.  Should  it  occur  that  the  operation  is  performed  for  the  removal  of 
a  foreign  body  from  the  trachea  or  lar^Tix  it  is  wise  to  have  an  experienced 
assistant  prepared  to  catch  the  foreign  body  the  moment  the  trachea  is  opened, 
inasmuch  as  such  a  body  is  frequently  forced  out,  together  with  a  lot  of  tena- 
cious mucus,  the  moment  the  trachea  is  incised.  After  this  there  is  usually  a 
deep  inspiration  which  may  again  draw  the  substance  into  the  trachea  and 
possibly  cause  it  to  become  lodged  in  one  of  the  larger  bronchi.  And  it  may 
be  difficult  to  dislodge  it  from  such  a  point. 

In  the  after-treatment  it  is  wise  to  guard  against  the  irritation  of  the  lungs 
on  account  of  the  effect  which  the  air  has  in  coming  directly  in  contact  with 
the  mucous  membrane  of  the  trachea  and  bronchi  without  first  passing  through 
the  nose  and  pharynx.  This  irritation  may  be  avoided  by  placing  over  the 
opening  a  wire  frame  on  which  a  layer  of  gauze  has  been  stretched,  which  is 
kept  moist  with  normal  salt  solution. 

The  tracheotomy  tube  should  consist  of  an  outer  and  inner  tube,  the  latter 
being  changed  frequently  enough  to  prevent  the  accumulation  of  mucus.  It 
is  a  good  rule  to  leave  a  tracheotomy  tube  in  place  as  short  a  time  as  possible, 
because  some  portion  of  the  outer  tube  is  liable  to  do  iniury  to  the  trachea, 
and  the  longer  it  is  left  in  place  the  greater  is  the  likelihood  of  permanent 
injury  being  done  to  this  structure. 

INTUBATION 

Since  the  introduction  of  antitoxin,  intubation  has  been  found  quite  suffi- 
cient to  relieve  the  obstruction  of  the  larynx  due  to  diphtheria.  It  is  rarely 
necessary  now  to  leave  a  tube  in  place  for  more  than  one  or  two  or,  at  most, 
three  days,  because  the  diphtheritic  membranes  have  usually  disappeared 
entirely  within  this  time  if  large  doses  of  antitoxin  have  been  given. 


I 


SURGERY  OF  THE  NECK  179 

Accompanying  difaculties  and  their  correction.  The  difficulties  -which 
accompany  intubation  are : 

1st.  The  danger  of  forcing  portions  of  the  diphtheritic  membrane  down 
into  t^e  trachea. 

2nd.     The  danger  of  injuring  the  vocal  cords. 

3rd.  The  danger  of  the  patient  coughing  out  the  tube  in  the  absence  of  the 
physician,  and  the  inability  of  the  nurse  to  replace  it. 

4th.  The  difficulty  some  people  have  in  taking  food  in  the  presence  of  an 
intubation  tube. 

5th.  In  rare  cases  the  intubation  tube  will  touch  a  point  in  the  larynx,  at 
the  base  of  the  epiglottis,  which  seems  to  produce  an  immediate  paralysis  of 
the  respiratory  centers,  causing  almost  instant  death  unless  artificial  respira- 
tion be  performed  until  the  effect  of  this  traumatism  has  passed  away. 

(1.)  The  first  difficulty  must  be  overcome  by  an  immediate  tracheotomy; 
consequently  the  surgeon  should  always  be  prepared  to  perform  a  tracheotomy 
before  he  begins  intubation.  This,  however,  becomes  necessary  only  very 
rarely,  but  when  it  does  the  conditions  are  so  urgent  that  unless  the  surgeon 
is  prepared  to  perform  tracheotomy  at  once  the  patient  will  probably  be  hope- 
lessly asphyxiated  before  the  necessary  preparations  can  be  made. 

(2.)  The  second  danger  can  be  avoided  by  great  care  in  performing  the 
operation. 

(3.)  Since  the  introduction  of  antitoxin  we  have  never  seen  a  case  in 
which  the  child  suffered  seriously  from  coughing  out  the  intubation  tube. 
"Whenever  this  has  happened  there  has  usually  been  at  the  same  time  a  loosen- 
ing of  a  portion  of  the  membrane  so  that  a  replacement  of  the  tube  was  not 
necessary. 

(4.)  Patients  who  find  difficulty  in  taking  nourishment  can  usually  be 
sustained  very  nicely  if  they  are  placed  in  the  inverted  position  and  permitted 
to  take  liquids  through  a  tube. 

The  first  and  most  important  condition  to  be  secured  in  order  to  make  a 
satisfactory  intubation  is  perfect  rest  and  quietude  of  the  patient. 

Technique.  If  a  patient  is  able  to  move,  even  though  to  a  slight  extent,  it 
will  be  difficult  to  insert  the  tube  without  causing  injurv'-  to  some  of  the  parts. 
To  secure  the  child  so  that  it  cannot  move  it  is  best  to  take  an  ordinary  sheet, 
have  the  child's  arms  placed  alongside  the  body,  and  then  wrap  the  sheet 
around  and  around  a  number  of  times  so  that  the  arms  cannot  be  removed 
from  the  sheet.  In  attempting  to  move  the  arms  the  child  will  pull  both  ways 
at  the  same  time  and  the  result  will  be  that  it  will  not  move  at  all.  The  child 
should  then  be  taken  upon  the  lap  of  an  assistant,  its  head  should  be  held 
against  the  left  shoulder,  the  left  arm  of  the  assistant  should  pass  across  the 
lower  portion  of  the  child's  chest,  while  the  right  arm  should  hold  its  head 
firmly  against  his  shoulder.  In  this  way  the  child  can  be  held  perfectly  still. 
The  gag  is  then  inserted  between  the  teeth  and  held  by  a  second  assistant  who 
stands  behind  the  one  holding  the  child.  The  surgeon  then  inserts  the  first 
finger  of  the  left  hand  into  the  mouth,  lifts  the  epiglottis  upwards  and  holds 
it  in  this  position  while  he  carries  the  tube  mounted  upon  the  applicator  into 
the  mouth  and  along  the  inner  side  of  the  index  finger.  This  will  guide  it 
directly  into  the  larynx.  It  is  pushed  down  into  the  larynx  gently  and  then 
released  from  the  applicator  by  the  mechanism  provided  for  that  purpose. 
At  the  same  time  the  index  finger  is  placed  upon  the  tip  of  the  tube  and  the 
latter  is  driven  down  so  that  the  rim  at  its  upper  end  rests  upon  the  broad 
surface  of  the  vocal  cords.  The  applicator  is  in  the  meantime  withdrawn 
quickly  and  this  will  enable  the  child  to  breathe  through  the  tube. 

It  is  wise  to  leave  a  firm,  silk  thread  attached  to  the  intubation  tube  and 
to  have  this  passed  out  through  the  angle  of  the  mouth  and  fastened  upon  the 


180  SURGERY  OF  THE  NECK 

cheek  by  means  of  rubber  adhesive  strips.  In  this  manner  the  removal  of  the 
tube  may  be  accomplished  by  the  nurse  in  case  it  should  become  occluded 
during  the  absence  of  the  surgeon, 

LARYNGOTOMY 

The  presence  of  a  foreign  body  in  the  larynx  underneath  the  vocal  cords, 
which  cannot  be  forced  out  by  the  efforts  of  the  patient  and  which  cannot 
conveniently  be  reached  through  a  tracheotomy  wound,  sometimes  necessitates 
the  splitting  of  the  larynx.  The  same  operation  is  occasionally  indicated  in  the 
presence  of  benign  growths  located  underneath  the  vocal  cords. 

The  important  point  in  this  operation  consists  in  the  thorough  anesthetiza- 
tion of  the  interior  of  the  larynx  by  means  of  a  spray  of  a  four  per  cent,  solu- 
tion of  cocaine  in  water.  The  patient  is  placed  in  the  Trendelenburg  position 
with  the  head  dependent  over  the  end  of  the  table.  An  incision  is  made  in  the 
median  line  extending  from  a  point  an  inch  above  the  prominence  of  the 
thyroid  cartilage  to  a  point  opposite  the  isthmus  of  the  thyroid  gland.  This 
incision  is  carried  down  to  the  larynx,  care  being  taken  to  grasp  all  of  the 
blood  vessels  at  once.  Just  before  opening  the  larynx  the  cocaine  spray 
should  again  be  applied,  it  having  been  thoroughly  applied  just  before  begin- 
ning the  operation.  Then  a  sharp  tenaculum  is  inserted  on  each  side  of  the 
median  line  and  while  an  assistant  makes  a  gentle  traction  upon  these  tenaculaB 
a  longitudinal  incision  is  made  through  the  larynx.  As  soon  as  the  larynx 
is  opened  there  is  usually  a  violent  attack  of  coughing  unless  the  part  has 
been  thoroughly  cocainized.  If  a  foreign  body  is  lodged  in  the  larynx  the 
first  effort  of  coughing  usually  forces  it  out,  and  the  same  precaution  should 
here  be  taken  that  was  mentioned  in  connection  with  tracheotomy  for  the 
removal  of  foreign  bodies  in  the  trachea.  An  assistant  should  be  ready  to 
sponge  away  any  mucus  that  is  forced  out  by  the  first  effort  of  coughing, 
because  this  is  likely  to  contain  the  foreign  body. 

In  case  the  operation  is  performed  for  the  removal  of  a  growth  the  larynx 
should  again  be  sprayed  with  cocaine  after  it  has  been  opened  in  order  that 
the  operation  may  not  be  interrupted  on  account  of  coughing  due  to  an  irrita- 
tion of  the  mucous  membrane.  The  diseased  portions  may  then  be  so  perfectly 
exposed  that  their  removal  is  not  connected  with  any  difficulty.  Hemorrhage 
is  controlled  in  the  usual  way,  and  after  the  operation  has  been  completed  the 
wound  is  closed  by  means  of  deep  and  superficial  sutures.  The  deep  sutures 
should  not  enter  the  larynx, 

LARYNGECTOMY 

In  the  presence  of  a  malignant  growth  confined  to  some  portion  of  the 
larynx  its  removal  is  indicated  if  the  surgeon  be  fairly  certain  that  there  has 
been  no  secondary  involvement. 

The  same  preparations  mentioned  in  connection  with  laryngotomy  should 
be  practised  in  laryngectomy.  If  there  has  been  sufficient  obstruction  to  the 
entrance  of  air  for  a  considerable  time  before  the  patient  comes  under  the 
care  of  the  surgeon  to  greatly  reduce  the  strength  of  the  patient  a  preliminary 
tracheotomy  should  be  done  so  that  the  general  condition  may  be  improved 
before  the  radical  operation  is  undertaken.  If  the  obstruction  is  not  sufficient 
to  seriously  interfere  with  the  patient's  breathing  then  it  is  just  as  well  to  do 
the  operation  at  once  without  having  made  a  preliminary  tracheotom3^ 

A  study  of  the  literature  seems  to  show  that  for  the  expert  surgeon  it  is 
undoubtedly  perfectly  proper  to  perform  this  operation  in  one  stage,  because 
he  will  be  able  to  take  the  necessary  precautions  to  prevent  the  infection  of  the 


SURGERY  OF  THE  NECK  181 

loose  connective  tissue  spaces  at  the  lower  end  of  the  incision,  which  lead 
directly  down  into  the  region  of  the  mediastinum.  Most  deaths  occur  as  a 
result  of  infection  through  this  space  and  consequently  it  is  most  important 
to  guard  against  it.  This  can  be  accomplished  most  readily  by  producing  a 
connective  tissue  barrier  by  laying  bare  the  trachea  for  a  distance  of  4  cm. 
below  the  cricoid  cartilage  and  tamponing  this  space  with  iodoform  gauze  for 
a  period  of  one  week,  by  which  time  the  loose  connective  tissue  spaces  will  have 
all  been  obliterated  and  it  will  be  possible  for  the  surgeon  to  perform  the 
remaining  steps  of  the  operation  with  greater  safety.  It  will,  however,  not  be 
a  sufficient  protection  to  warrant  anj^thing  but  the  most  perfect  closure  of  the 
pharynx.  During  the  interval  of  this  week  the  patient  should  receive  an 
extensive  X-ray  treatment  of  twenty  minutes  duration  each  day,  the  neck  being 
shielded  by  an  aluminum  plate  of  one  mm.  thickness. 

The  operation  should  again  be  performed  with  the  patient  in  the  Trende- 
lenburg position,  with  the  head  dependent  over  the  end  of  the  table  in  order 
to  prevent  the  entrance  of  blood  into  the  trachea. 

The  method  of  anesthesia  practised  in  connection  with  thyroidectomy 
should  be  employed  in  this  operation,  but  in  addition  to  this  the  larynx  should 
be  sprayed  thoroughly  with  four  per  cent,  cocaine  for  ten  minutes  before 
beginning  the  anesthesia  in  order  that  the  patient  may  not  cough  when  the 
trachea  is  opened.  It  is  important  for  the  patient  to  inspire  deeply  during  the 
use  of  the  spray  in  order  that  some  of  the  cocaine  may  reach  the  lining  of  the 
trachea. 

It  is  important  also  that  the  patient  be  very  thoroughly  anesthetized  before 
the  operation  is  begun  in  order  that  no  further  ether  need  be  given  during 
the  progress  of  the  operation. 

The  advantage  of  this  method  is  really  of  much  importance  both  to  the 
comfort  of  the  surgeon  and  the  safety  of  the  patient. 

Technique.  An  incision  is  made  from  a  point  an  inch  and  a  half  above  the 
prominence  of  the  thyroid  cartilage  to  a  point  just  above  the  sternum.  The 
vessels  overlying  the  larynx  and  trachea  are  carefully  caught  with  hemostatic 
forceps  and  cut.  The  isthmus  of  the  thyroid  is  grasped  between  two  pairs  of 
hemostatic  forceps,  cut  and  ligated.  After  the  larynx  and  trachea  have  been 
carefully  laid  bare  a  tenaculum  may  be  inserted  into  the  third  or  fourth  ring 
of  the  trachea  and  the  latter  cut  transversely.  It  is  then  rapidly  drawn  up 
and  loosened  so  that  its  upper  end  faces  forwards  and  acts  as  a  curved  tube 
communicating  with  the  anterior  surface  of  the  neck.  It  is  dissected  loose 
sufficiently  to  project  half  an  inch  beyond  the  margin  of  the  skin,  .which  is 
button-holed  a  short  distance  below  the  lower  end  of  the  incision,  so  that  the 
end  of  the  trachea  may  be  drawn  through.  This  will  aid  in  preventing  the 
discharge  from  the  wound  from  entering  the  trachea  and  causing  aspiration 
pneumonia.  It  is  then  sutured  in  place  by  means  of  several  fine  sutures  which 
extend  through  the  third  or  fourth  ring  of  the  trachea.  The  upper  portion  of 
the  skin  incision  is  left  open  to  facilitate  the  remaining  steps  of  the  operation 
necessary  to  remove  the  larynx.  In  this  manner  the  patient  is  enabled  to 
breathe  without  the  danger  of  inspiring  blood.  It  is  also  possible  by  placing 
the  anesthetic  upon  a  piece  of  gauze  held  over  the  end  of  the  trachea  to 
continue  the  anesthesia  without  annoyance. 

The  larynx  is  now  carefully  dissected  out,  beginning  from  below,  loosening 
both  sides  simultaneously  and  controlling  the  hemorrhage  step  by  step  by 
means  of  hemostatic  forceps  and  ligatures.  It  is  well  to  keep  the  larynx  and 
trachea  cocainized  in  order  to  prevent  the  annoyance  due  to  coughing.  "When 
the  upper  end  of  the  larynx  is  reached  care  should  be  taken  to  cut  its  attach- 
ment in  the  pharjmx  so  that  the  latter  can  be  closed  by  means  of  sutures. 
If  the  pharynx  is  already  involved  in  the  malignant  growth  the  removal  of 


182  SURGERY  OF  THE  NECK 

the  larynx  is  practically  useless  and  a  simple  tracheotomy  will  be  of  quite 
as  much  benefit  to  the  patient ;  consequently  in  cases  proper  for  the  removal 
of  the  larynx  these  flaps  can  be  formed  without  fear  of  leaving  portions  of 
the  carcinoma.  The  pharynx  is  then  carefully  closed,  preferably  with  two 
rows  of  sutures,  a  piece  of  iodoform  gauze  is  carefully  tamponed  underneath 
the  wall  thus  formed  in  order  to  provide  drainage  in  case  of  leakage.  The 
remaining  portion  of  the  wound  is  then  carefully  sutured  by  means  of  deep 
and  superficial  sutures. 

It  is  usually  not  necessary  to  insert  a  tracheotomy  tube  in  a  trachea 
which  has  been  brought  out  in  the  manner  just  described.  The  skin  should 
be  carefully  sutured  above  and  below,  and  it  is  well  to  protect  the  wound 
against  infection  from  the  mucus  expelled  from  the  trachea  by  the  applica- 
tion of  some  oily  substance,  such  as  vaseline.  The  dressing  must  necessarily 
be  small  in  order  that  the  entrance  to  the  trachea  be  not  obstructed  in  any 
way.  The  same  precaution  should  be  taken  against  irritation  from  the  direct 
introduction  of  air  into  the  trachea  that  was  mentioned  in  connection  with 
tracheotomy,  A  frame  covered  with  gauze  should  be  fastened  over  the  open- 
ing and  kept  moist  by  the  application  of  a  small  amount  of  normal  salt  solu- 
tion. As  soon  as  the  wound  has  healed  an  artificial  larynx  may  be  fitted 
into  the  trachea.  It  is  claimed  that  a  sufficient  amount  of  air  can  be  retained 
in  the  pharynx  to  give  an  audible  voice  sound,  making  the  use  of  an  artificial 
larynx  unnecessary. 

We  have  seen  one  case  in  which  the  patient  could  make  all  of  his  wants 
known  with  perfect  ease,  and  could  even  engage  in  conversation.  The  total 
amount  of  air  available  at  any  time  is,  however,  so  slight  that  the  speech  is 
quite  spasmodic. 

Until  one  has  considerable  experience  in  performing  the  operation  of 
laryngectomy  it  is  better  to  do  the  operation  in  two  stages  because  in  this 
manner  one  can  prevent  infection  of  the  mediastinal  space  with  almost  abso- 
lute certainty.  The  first  step  consists  in  laying  free  the  field  throughout  and 
also  the  upper  three  cm.  of  the  trachea  and  then  tamponing  the  space  with 
gauze  all  about  the  larynx  and  the  upper  end  of  the  trachea,  which  will  cause 
the  formation  of  granulation  tissue  to  protect  the  deep  tissues  against  infec- 
tion. The  interval  between  the  two  steps  of  the  operation  should  be  from 
one  week  to  ten  days.  In  case  the  operation  is  performed  for  the  relief 
of  a  malignant  growth  a  daily  treatment  of  X-ray  should  be  given  through 
the  open  wound  during  the  interval  between  the  operations. 

The  second  stage  of  the  operation  should  simply  complete  the  steps  as 
described  above. 

ESOPHAGOTOMY 

Foreign  bodies  frequently  become  lodged  in  the  esophagus  at  a  point 
behind  the  upper  end  of  the  sternum.  Usually  it  is  possible  to  grasp  them 
with  esophagus  forceps  and  remove,  especially  if  they  are  of  material  which 
makes  it  possible  to  locate  them  by  the  use  of  a  fluoroscope,  with  the  X-ray 
tube  behind  the  patient  and  the  surgeon  in  front.  We  have  been  able  to  pass 
a  forceps  into  the  esophagus,  to  open  its  jaws  at  the  moment  it  touched  the 
foreign  body,  and  to  grasp  the  body  conveniently  for  removal.  If  this  can 
not  be  done  through  the  mouth  it  may  frequently  be  done  through  an  esopha- 
gotomy  opening. 

Technique.  An  incision  seven  cm.  long  is  made  along  the  anterior  border 
of  the  lower  end  of  the  stemo-cleido-mastoid  muscle,  the  lower  end  extending 
to  a  point  one  cm.  above  the  clavicle. 

The  skin,  fascia  and  platysma  are  severed.  The  sterno-cleido-mastoid 
muscle  is  retracted  outward  and  the  sterno-thyroid  and  hyoid  muscles  are 


SURGERY  OF  THE  NECK  183 

retracted  inward,  the  omohyoid  is  severed,  the  outer  capsule  of  the  thyroid 
gland  is  split  and  the  lobe  of  the  gland  is  retracted  upward.  The  deep  fascia 
is  then  split,  exposing  the  inferior  thyroid  artery,  which  extends  inwards 
and  upwards  across  the  interior  border  of  the  longus  colli  muscle.  This 
vessel  is  clamped  between  two  pair  of  hemostatic  forceps,  cut  and  ligated. 
At  this  point  the  same  care  must  be  exercised  in  protecting  the  recurrent 
laryngeal  nerve  that  was  described  in  thyroidectomy.  It  crosses  the  inferior 
thyroid  artery  in  the  form  of  a  delicate  white  thread-like  structure.  It  is 
well  to  retract  the  nerve  with  a  tine  tenaculum  toward  the  median  line. 

It  is  important  to  open  the  esophagus  laterally  and  not  anteriorly,  because 
of  the  danger  of  wounding  the  nerve. 

A  large  steel  urethral  sound,  or  an  olive-pointed  esophagus  dilator,  is  now 
inserted  through  the  mouth  and  two  fine-toothed  forceps  are  caught  in  the 
side  of  the  esophagus,  or  the  same  result  may  be  accomplished  by  placing 
two  fine  silk  sutures,  one  cm.  apart,  in  the  side  of  the  esophagus  and  making 
a  longitudinal  incision  through  the  wall  half  way  between,  the  two  sutures 
or  forceps  being  used  as  retractors. 

A  large  Jacob 's  retention  catheter,  or  a  soft  rubber  tube,  is  inserted  into 
the  esophagus  through  the  wound  and  held  in  place  by  a  suture.  This  tube 
should  extend  at  least  a  distance  of  20  cm,  into  the  esophagus  so  that  liquid 
nourishment  may  be  passed  down  through  it. 

The  wound  is  tamponed  widely  open  with  gauze  and  moist  antiseptic 
dressings  are  applied  and  renewed  every  two  hours,  as  the  discharge  through 
a  fistula  in  the  esophagus  is  likely  to  be  very  offensive. 

If  the  foreign  body  has  not  been  lodged  long  enough  to  cause  infection, 
the  wound  in  the  esophagus  may  be  sutured  at  once  with  catgut,  but  should 
nevertheless  be  kept  widely  open  with  tampons. 

If  the  operation  is  performed  for  the  relief  of  obstruction  of  the  pharynx 
or  esophagus  above  this  point  a  permanent  esophageal  tube  may  be  intro- 
duced to  facilitate  the  feeding  of  the  patient,  or  the  edges  of  the  wound  in 
the  esophagus  may  be  sutured  to  the  edges  of  the  skin  wound,  which  will 
enable  the  patient  to  use  a  removable  esophagus  tube  later  on.  In  most  cases, 
however,  the  patient  is  not  likely  to  profit  much  by  this  operation  for  the 
relief  of  obstruction  due  to  carcinoma.  We  have  never  encountered  a  case 
in  which  the  operation  was  necessary  for  the  relief  of  obstruction  due  to 
cicatricial  occlusion,  although  such  cases  are,  of  course,  possible. 


PART  IV 

SURGERY  OF  THE  CHEST 


EMPYEMA 


The  most  common  pathological  condition  of  the  chest  for  which  surgical 
treatment  is  indicated  is  an  accumulation  of  pus  in  the  cavity  thereof,  the 
result  of  an  infection  due  to  the  specific  micro-organisms  present  in  a  pre- 
ceding pneumonia,  or  to  the  infection  of  the  pleura  by  means  of  the  bacillus 
of  tuberculosis,  or  any  one  of  the  pus-producing  micro-organisms.  The  condi- 
tion is  usually  preceded  by  an  inflammation  of  the  pleura  accompanied  with 
serous  effusion  into  the  pleural  cavity,  which  later  becomes  infected.  This 
giA'es  rise  to  the  formation  of  the  pus  characterizing  the  condition  of  empyema. 

Signs  and  symptoms.  There  is  usually  a  history  of  pneumonia  accom- 
panied by  severe  pleuritic  pains,  or  a  history  of  apex  tuberculosis.  During 
the  accumulation  of  pleuritic  fluid  there  is  shortness  of  breath  and  a  short, 
irritable,  hacking  cough.  If  the  disease  is  due  to  a  tuberculous  infection 
an  evening  temperature  is  likely  to  be  noted ;  if  due  to  an  infection  by  the 
pneumococcus  the  temperature  is  liable  to  be  persistent. 

There  is  a  bulging  of  the  side  of  the  chest  involved ;  upon  percussion 
there  is  dullness  which  varies  with  the  position  of  the  patient,  except  in  cases 
in  which  the  two  layers  of  the  pleura  are  adherent  above  the  empyema.  This 
condition  is  usually  not  present  except  in  recent  cases,  hence  it  is  not  diffi- 
cult to  differentiate  between  the  late  stages  of  empyema  and  hydrothorax 
by  physical  examination.  If  the  empyema  is  extensive  there  is  usually  a 
displacement  of  the  heart.  A  good-sized  trocar  inserted  between  the  ribs 
over  the  middle  of  the  area  of  dullness  may  discover  pus,  but  the  absence 
of  pus  should  not  be  considered  as  proof  of  the  non-existence  of  an  empyema, 
because  it  frequently  happens  that  the  pus  is  so  much  thickened  that  it 
cannot  be  withdrawn  even  through  a  large  trocar.  The  trocar  is  useful  to 
differentiate  between  hydrothorax  and  an  empyema,  as  in  the  former  condi- 
tion the  fluid  is  sufficiently  thin  to  be  forced  out  through  the  instrument.  In 
tubercular  empyema  there  is  frequently  much  coagulated  serum  which  cannot 
be  forced  even  through  a  large  trocar. 

Glycerine-formalin  solution.  Murphy  well  demonstrated  that  in  a  large 
proportion  of  cases  which  come  under  treatment  reasonably  early  the  empyema 
will  absorb  and  leave  the  patient  in  an  ideal  condition  if  a  portion  of  the  pus 
contained  in  the  pleural  cavity  is  withdrawn  and  the  following  solution 
injected  through  the  trocar :  viz.,  a  two  per  cent,  glycerine  solution  of  formalin 
which  contains  forty  per  cent,  of  formaldehyde.  It  is  always  kept  ready 
for  use  so  that  it  is  never  necessary  to  use  this  preparation  recently  mixed. 
This  is  important  because  in  the  freshly  prepared  solution  there  are  always 
little  globules  of  formaline  which  will  cauterize  any  surface  Avith  which  they 
come  in  contact,  while  in  the.  mixture  which  has  stood  for  a  number  of  days 
the  solution  is  perfect  and  this  accident  does  not  occur.  From  ten  to  sixty 
cc.  of  this  solution  are  injected  into  the  pus  remaining  in  the  chest  cavity 

185 


186  SURGERY  OF  THE  CHEST 

after  a  portion  of  pus  has  been  removed  through  a  trocar  to  which  a  rubber 
tube  at  least  thirty  cm,  long  is  attached  to  prevent  the  patient  from  filling 
the  chest  cavity  with  air  by  some  sudden  inspiration.  The  progress  of  the 
case  determines  the  time  at  which  this  treatment  is  to  be  repeated,  and  the 
number  of  repetitions. 

Beck's  bismuth  paste.  Recently  a  number  of  cases  have  been  cured  by 
the  injection  of  Beck's  bismuth  paste.  Not  to  exceed  200  cc.  of  10  per  cent, 
absolutely  pure  bismuth  subnitrate  are  injected  through  the  canula  through 
which  the  pus  has  been  drained  out  of  the  cavity.  This  should  be  repeated 
every  ten  to  fifteen  days  until  the  area  of  dullness  begins  to  decrease. 

The  amount  of  bismuth  injected  in  this  manner  is  not  sufficient  to  result 
in  poisoning,  but  in  case  a  patient  should  be  uncommonly  susceptible  to  this, 
it  is  possible  to  recognize  the  condition  by  the  early  appearance  of  a  dark 
line  on  the  gums  along  the  edge  of  the  teeth. 

In  these  cases  the  operation  of  rib  resection  and  drainage  (to  be  described 
directly)  should  be  employed  at  once.  It  is  well  also  to  fill  the  cavity  with 
warm  olive  oil  and  to  then  permit  this  to  drain  away,  as  it  will  carry  with  it  a 
quantity  of  the  bismuth. 

Anesthesia.  In  the  presence  of  pus  in  the  pleural  cavity  in  cases  not 
yielding  to  the  treatment  just  described,  an  operation  is  always  indicated. 
If  the  patient's  condition  does  not  warrant  the  use  of  a  general  anesthetic 
the  operation  may  be  performed  with  the  use  of  a  one  per  cent,  solution 
of  cocaine  injected  into  the  skin  and  into  the  sheaths  of  intercostal  nerves 
a  slight  distance  above  the  point  at  which  the  operation  is  to  be  done.  The 
point  to  be  chosen  for  the  operation  is  the  middle  of  the  area  of  dullness, 
usually  about  the  sixth  or  seventh  rib. 

Technique.  An  incision  from  two  to  six  inches  in  length  is  made  parallel 
with  the  rib  in  the  posterior  axillary  line,  A  longitudinal  incision  is  made 
through  the  periosteum  and  this  is  removed  by  means  of  a  periosteal  elevator. 
A  pair  of  bone-cutting  forceps,  or  especially  devised  rib-cutting  forceps  or 
shears,  is  then  carefully  applied  to  the  rib  at  the  posterior  end  of  the  wound ; 
the  rib  is  cut  off,  grasped  by  a  pair  of  bone-holding  forceps  and  lifted 
out  of  its  periosteum  to  the  extent  to  which  its  removal  is  desired.  It  is 
then  cut  off  at  this  point  with  the  bone-cutting  or  rib-cutting  forceps.  The 
periosteum  of  the  rib  and  the  pleura  now  lie  between  the  abscess  and  the 
operator.  If  the  empyema  has  existed  for  a  short  time  only  it  is  not  neces- 
sary to  remove  more  than  one  segment  of  rib,  but  if  it  has  existed  for  a 
considerable  period  it  is  often  wise  to  remove  a  portion  of  two  or  more  ribs  at 
once  in  order  to  insure  a  sufficient  amount  of  space  for  permanent  drainage,  as 
well  as  to  provide  for  a  certain  amount  of  contraction  of  the  chest  wall. 

Drainage  and  non-irrigation.  A  longitudinal  incision  is  now  made  through 
the  middle  of  the  periosteum  in  order  to  avoid  the  intercostal  vessels  and 
nerves.  This  will  permit  the  pus  to  escape  from  the  pleural  cavity.  It  is 
well  to  make  this  incision  sufficiently  large  for  perfect  drainage.  By  insert- 
ing the  finger  through  this  opening  one  can  determine  accurately  the  extent 
of  the  pus  cavity.  A  long  pair  of  dressing  forceps  is  now  passed  through 
this  opening,  across  the  cavity  explored,  and  its  end  is  forced  out  between 
two  ribs  on  the  anterior  surface  of  the  chest  wall  at  a  point  suitable  to  the 
conditions  present.  An  opening  is  cut  down  upon  the  forceps  and  two  per- 
forated rubber  drainage  tubes  at  least  half  an  inch  in  diameter  are  drawn 
through  this  opening  into  the  chest  and  out  of  the  original  incision  behind. 
They  are  protected  by  means  of  safety  pins  at  each  end,  and  after  the  pus  has 
been  permitted  to  escape  a  large  dressing  composed  of  aseptic  gauze  and 
absorbent    cotton   is    applied    over   both   openings.     Neither   irrigation   nor 


SURGERY  OF  THE  CHEST  187 

sponging  is  made  use  of.  This  dressing  is  changed  as  frequently  as  soiled, 
but  irrigation  is  not  practised  at  any  time. 

In  large  accumulations  of  pus  in  the  pleural  cavity,  especially  if  there 
is  a  communication  between  the  abscess  and  a  bronchial  tube,  it  is  often  not 
safe  to  operate  with  the  patient  in  the  recumbent  position.  In  such  a  case 
it  is  best  to  aspirate  most  of  the  pus  through  a  trocar  at  least  two  mm.  in 
diameter  or  to  operate  with  the  patient  in  the  prone  posture. 

Lilienthal  has  shown  that  patients  suffer  much  less  from  difficulty  in 
respiration  when  the  chest  wall  has  been  opened  when  they  are  in  a  prone 
position.  This  fact  can  often  be  used  to  advantage  .after  the  operation  has 
been  completed.  By  carefully  arranging  the  pillows  so  that  the  patient 
can  take  a  comfortable  position,  lying  prone,  many  recover  more  easily  if 
this  position  is  maintained. 

This  seems  true  especially  in  patients  suffering  from  empyema  in  both 
sides  of  the  chest.  In  these  it  is  important  to  operate  in  two  stages,  the 
side  containing  the  greater  amount  of  pus  being  chosen  for  the  first  opera- 
tion, and  the  second  operation  being  postponed  as  long  as  the  patient  con- 
tinues to  improve  after  the  first  operation.  If  possible  it  is  best  to  await 
the  time  when  the  drainage  tubes  inserted  at  the  time  of  the  first  operation 
have  been  permanently  removed.  If  this  is  not  possible,  however,  the  drain- 
age opening  on  the  side  first  operated  should  be  covered  by  gauze  pads 
spread  with  a  handful  of  vaseline,  producing  a  perfect  seal,  so  that  it  will 
not  be  possible  for  a  collapse  of  both  lungs  to  take  place  at  the  same  time. 

A  second  piece  of  gauze  with  an  equal  amount  of  vaseline  is  kept  in 
readiness  in  case  of  necessity  to  protect  the  other  cavity  after  it  has  been 
opened.  The  operation  is  performed  with  the  patient  lying  flat  upon  his 
chest  and  abdomen,  and  this  position  is  maintained  after  the  operation  until 
he  finds  by  experimenting  that  he  can  lie  upon  his  side  or  back  with  com- 
fort. 

It  is  important  in  dressing  these  cases  to  take  the  same  precautions  to 
prevent  trouble  from  collapse  of  both  lungs.  For  this  reason  the  wounds 
on  only  one  side  should  be  exposed,  and  the  other  side  should  not  be  dressed 
on  the  same  day  if  there  has  been  any  disturbance  of  respiration  during  the 
dressing  of  the  first  wound. 

We  have  operated  only  a  few  of  these  cases  and  it  may  be  possible  that 
by  the  use  of  the  Melzer  and  Auer  apparatus,  or  a  cabinet  with  pressure 
control,  one  can  perform  the  operations  more  conveniently,  but  in  none 
of  our  cases  did  we  encounter  serious  difficulties  by  following  the  methods 
just  described. 

In  these  cases,  furthermore,  the  operation  should  always  be  performed 
with  the  greatest  possible  rapidity. 

After-treatment.  In  the  after-treatment  it  is  important  in  the  first  place 
to  secure  perfect  drainage,  which  is  insured  in  the  operation  which  has  been 
described  from  the  fact  that  the  drainage  tubes  extend  entirely  across  the 
pus  cavity  and  consequently  when  the  diaphragm  encroaches  upon  this  cavity 
from  below  and  the  lung  from  above  the  through  drainage  persists.  Were 
there  but  one  opening  in  the  chest  wall  a  pocket  might  readily  form  at  some 
point,  but  with  the  precaution  of  having  two  openings  with  drainage  tubes 
extending  from  one  to  the  other  this  cannot  occur. 

It  is  important  to  make  the  dressing  large  enough  to  completely  close 
the  opening  against  the  entrance  of  air  from  without  and  to  insure  this  by 
carefully  applying  bandages  around  the  dressings  to  hold  them  in  the  desired 
position. 

After  the  discharge  has  been  greatly  reduced  it  is  wise  to  begin  giving 
the  patient  systematic  breathing  exercises.    He  should  be  directed  to  inhale 


188  SURGERY  OF  THE  CHEST 

as  fully  as  possible  through  the  nose,  keeping  the  mouth  closed,  and  then 
to  blow  out  forcibly  through  a  tube  with  an  aperture  of  about  two  milli- 
meters diameter.  These  exercises  should  be  frequently  repeated  during  the 
day.  It  is  well  to  continue  in  this  respect  for  many  months  after  the  patient 
has  recovered,  because  it  will  aid  in  overcoming  the  deformity  which  is  sure 
to  be  present  to  some  extent  after  the  operation. 

Danger  of  supervening  tuberculosis.  Even  in  cases  of  empyema  not  com- 
plicated with  tuberculosis  there  is  always  a  greater  tendency  to  the  develop- 
ment of  this  disease  than  in  normal  lungs ;  consequently  these  patients  should 
be  advised  to  live  under  favorable  hygienic  surroundings  and  the}'  should 
be  given  general  tonics  whenever  their  condition  of  health  requires.  If  there 
is  any  suspicion  of  the  presence  of  tuberculosis  anti-tubercular  measures  should 
be  used  for  a  long  period  after  recovery  from  the  operation.  If  the  empyema 
has  resulted  from  a  traumatism,  such  as  a  penetrating  wound,  especially  a 
gun-shot  wound  made  with  ordinarj^  firearms,  the  infection  is  frequently  due 
to  the  fact  that  some  portion  of  clothing  has  been  carried  into  the  pleural 
cavity  and  consequently  it  is  well  in  these  cases  to  make  the  opening  in  the 
posterior  axillary  line  sufficiently  large  to  enable  an  examination  of  the 
cavity  for  such  substances. 

Continuance  of  the  drainage.  It  is  Avell  to  leave  the  drainage  tubes  in 
place  until  one  is  certain  that  the  entire  cavity  has  been  closed  down  to  these, 
because  if  they  are  left  in  place  a  little  too  long  no  harm  can  come  from  it, 
while  if  they  are  removed  too  soon  a  new  pocket  of  pus  may  form,  necessi- 
tating a  secondary  operation.  If  it  seems  desirable  to  reduce  the  size  of  the 
drainage  tube  it  is  well  to  draw  smaller  tubes  through  the  entire  distance 
so  that  the  through  drainage  is  maintained  as  long  as  drainage  is  made  use  of. 
If  the  granulations  in  the  space  occupied  by  the  drainage  seem  flabby  or 
unhealthy  it  is  good  practice  to  drop  a  small  quantity  of  strong  compound 
tincture  of  iodine  into  the  cavity  in  order  to  produce  a  stimulating  influ- 
ence. 

Although  these  cases  usually  progress  favorably  occasionally  one  is  en- 
countered in  which  healing  is  greatly  retarded,  or  in  which  fistulas  or  abscesses 
persist  for  a  long  time  after  the  original  operation. 

FISTULA  AND  ABSCESSES  FOLLOWING  OPERATIONS  FOR 

EMPYEMA 

Although  the  relative  proportion  of  persistent  fistula  and  abscesses  is 
not  so  great  as  formerly  after  operations  for  the  relief  of  empyema  of  the 
chest,  since  surgeons  take  the  same  precautions  as  in  aseptic  cases  to  prevent 
secondary  infection  during  and  after  this  operation,  they  are  still  sufficiently 
common  to  be  a  source  of  much  annoyance. 

There  are,  of  course,  other  elements  of  value  from  the  standpoint  of 
prophylaxis,  aside  from  that  of  aseptic  operation  and  after-treatment. 

The  method  advised  by  Murphj^  of  aspiration  and  subseqvient  injection 
into  the  pleural  cavity  of  60  cc.  of  a  2  per  cent,  solution  of  formalin  in 
glycerine,  and  the  plan  of  making  tubular  through  drainage  in  case  of  opera- 
tion instead  of  simply  making  drainage  into  the  pleural  cavity,  should  be 
mentioned  especially.  The  former  method  of  treatment  makes  the  latter 
unnecessary  in  many  cases,  and  the  latter  method  reduces  the  number  of 
persistent  fistulae  and  abscesses  to  a  minimum,  because  it  eliminates  the  forma- 
tion of  pockets. 

Beck's  bismuth  paste.  In  cases  in  which  these  sinuses  or  abscesses  persist, 
however,  in  which  formerly  the  method  of  Estlander  and  Schede  gave  the 
most  reasonable  promise   of  ultimate  success,  surgical  treatment  has  often 


SURGERY  OF  THE  CHEST  189 

been  most  disappointing.  It  is  just  in  this  class  of  cases  that  the  method 
introduced  by  Dr.  Emil  Beck  has  given  the  most  satisfactory  results. 

The  method  consists  in  filling  the  sinus  or  pus  cavity  with  a  mixture  of 
bismuth  subnitrate  and  keeping  this  in  position  hy  plugging  the  outer  open- 
ing with  gauze.  The  mixture  consists  of  one  part  of  arsenic-free  subnitrate 
of  bismuth  and  two  parts  of  sterile  amber  vaseline. 

This  mixture  is  injected  every  second  day  until  suppuration  has  disap- 
peared. The  injections  are  repeated  as  often  as  necessary  to  keep  the  sinus 
or  pus  cavity  constantly  filled  with  the  preparation.  At  first  it  is  neces- 
sary to  do  this  every  day  or  every  second  day,  then  every  third  and  so 
on  until  it  may  be  necessary  to  inject  not  oftener  than  once  a  week  or  ten 
days. 

We  have  employed  this  form  of  treatment  in  many  cases  and  it  shows 
results  which  are  much  better  than  those  obtained  previously. 

One  feature  has  been  most  striking.  In  cases  that  were  in  a  septic  con- 
dition when  the  treatment  was  commenced,  the  improvement  of  the  general 
condition  of  the  patient  was  especially  marked.  Pulse  and  temperature  be- 
came normal  within  a  few  days  and  the  general  appearance  of  the  patient 
lost  the  characteristics  of  sepsis.  The  nutrition  improved  and  the  anemia 
disappeared  rapidly.  The  discharge  from  the  sinuses  usually  becomes  sterile 
in  a  short  time. 

To  illustrate  this  a  short  abstract  of  the  history  of  the  following  case  will 
by  typical. 

An  illustrative  case.  A.  S.,  an  Italian  laborer,  sixty  years  of  age,  had  a  pneumonia  fol- 
lowed by  empyema  of  the  right  thorax  seven  months  ago.  The  pleural  cavity  was  drained; 
a  sinus  persisted,  leading  into  a  large  cavity.  Three  months  later  Estlander's  opera- 
tion was  performed  with  excision  of  three  ribs.  The  patient  was  in  a  severely  septic  and 
anemic  condition  when  he  entered  the  hospital.  An  injection  of  720  cc.  of  the  bismuth  mixture 
was  given  and  the  patient  put  to  bed.  In  two  days  60  cc.  more  were  injected,  but  by  this  time 
the  septic  condition  had  markedly  decreased,  and  within  a  week  the  patient  became  normal  and 
his  anemia  began  to  disappear.  For  one  month  injections  were  made  every  second  day,  the 
quantity  in  the  meantime  decreased  to  35  cc.  and  the  patient  acquired  a  rosy  appearance.  Then 
he  was  sent  home, — at  first,  to  return  twice  a  week  to  have  a  few  cc.  injected,  and  later  only 
once  a  week,  a  sufficient  amount  being  used  each  time  to  fill  but  not  to  distend  the  cavity. 

Nine  months  later  his  general  health  was  perfect  and  there  was  but  a  superficial  sinus  which 
held  scarcely  5  cc.  of  the  paste,  and  which  would  undoubtedly  heal  completely  in  a  short  time. 

A  second  case  seems  worthy  of  special  description  because  it  is  one  of 
those  that  were  formerly  extremely  difficult  to  heal, 

F.  C,  American,  age  thirty-five,  miner,  had  a  severe  fall  nine  months  ago  while  working 
in  the  mountains;  this  was  followed  by  pneumonia  and  then  by  a  right-sided  empyema.  This 
was  drained  through  a  rib-resection  opening.  Seven  months  later  an  Estlander  operation  was 
made,  with  resection  of  three  ribs.  At  the  end  of  two  months  the  patient  came  under  our 
care.  At  this  time  there  was  a  sinus  discharging  pus  freely,  and  the  patient  coughed  up  the 
same  material.  This  was  before  we  were  familiar  with  the  bismuth  paste  treatment — so  we 
performed  Schede's  operation.  The  patient  did  well  for  nearly  a  week,  when  he  developed  a 
phlebitis  in  both  femoral  veins.  He  became  markedly  septic  and  emaciated.  Four  weeks  later 
he  still  expectorated  pus,  and  there  was  a  free  drainage  of  pus  from  the  wound  when  we  began 
the  injection  of  No.  1  bismuth  paste.  He  expectorated  much  of  the  650  cc.  of  the  paste  injected. 
The  injection  was  repeated,  each  time  simply  filling  the  cavity  without  using  any  force.  The 
pus  and  sepsis  subsided  rapidly.  In  ten  days  he  appeared  like  a  different  person,  and  in  twelve 
weeks  he  was  perfectly  well. 

Conclusions  and  further  details.  This  treatment  has  proven  most  satis- 
factory. "We  have  used  it  only  in  cases  with  sinuses,  although  it  has  been 
suggested  to  aspirate  the  pus  in  empyema  and  to  inject  the  paste  into  the 
pleural  cavity  through  the  trocar. 


190  SURGERY  OF  THE  CHEST 

There  has  been  no  case  of  bismuth  poisoning  in  our  series  of  cases,  al- 
though this  might  easily  occur — as  it  has  when  cavities  in  other  portions  of 
the  body  have  been  filled  with  large  quantities  of  bismuth  paste.  If  this 
occurs,  Beck  advises  the  immediate  injection  of  hot  olive  oil,  110°  F.,  which 
will  dissolve  the  paste  and  facilitate  its  escape  through  the  outer  fistula  or 
through  a  drainage  tube,  which  may  be  inserted. 

The  injection  is  made  with  a  large,  ordinary  glass  syringe,  just  enough 
force  being  employed  to  fill  the  sinus  or  cavity,  but  not  enough  to  cause 
forcible  distension.  The  outer  opening  is  carefully  plugged  with  sterile 
gauze. 

In  a  few  cases  of  empyema,  accompanied  by  tuberculous  cavities  of  the 
lung,  in  which  the  patient  came  under  treatment  in  a  severely  septic  state, 
with  a  communication  between  the  sinus  and  the  cavity  in  the  lung,  so  that 
the  patient  would  expectorate  the  bismuth  paste  after  injection,  we  have  had 
remarkable  improvement. 

The  paste  seemed  to  result  in  a  disinfection  of  the  sinus  and  cavity  so 
that  the  symptoms  of  acute  sepsis  disappeared,  which  gave  the  patient  an 
opportunity  once  more  to  collect  some  strength  to  withstand  the  tuberculosis. 

CHRONIC  EMPYEMA 

Conditions  favoring  this  disease.  The  drainage,  followed  by  the  use  of 
Beck's  paste,  of  an  empyema  of  the  chest  does  not  always  result  in  the  com- 
plete cure  of  the  empyema.     This  may  be  occasioned: — 

1st.  By  the  contraction  of  the  lung  to  such  an  extent  as  to  leave  a  consid- 
erable space  which  is  not  filled  by  re-expansion. 

2d.    By  the  unyielding  condition  of  the  chest  wall. 

3d.  By  the  fact  that  there  are  sometimes  a  number  of  abscesses  sepa- 
rated from  each  other  by  adhesions  between  the  pulmonary  and  the  costal 
pleurae.  It  happens  occasionally  that  only  one  of  a  number  of  these  abscesses 
is  opened,  and  then  the  drainage  of  that  focus  can,  of  course,  not  relieve  the 
other  abscesses.  Frequently  there  are  small  sinuses  communicating  between 
the  different  pus  formations  so  that  there  is  a  constant  flow  from  an  undrained 
abscess  into  the  drained  one;  or  this  communication  may  from  time  to  time 
become  obstructed  and  then  the  drained  abscess  will  approach  complete  heal- 
ing only  to  have  a  new  discharge  of  pus  into  it  from  its  undrained  neighbor. 
In  such  instances  it  is  usually  possible  to  locate  the  other  abscesses  by  means 
of  percussion. 

Again  the  healing  may  be  prevented  because  of  the  inelasticity  of  the 
thickened  pleura  which  prevents  it  from  applying  itself  to  the  surface  of  the 
lung.  It  frequently  happens  that  the  costal  pleura  is  several  centimeters 
in  thickness.  There  may  also  be  a  necrosis  of  one  or  more  ribs  secondary  to 
the  pleuritic  infection,  which  may  again  account  for  the  fact  that  healing 
does  not  take  place.  In  still  other  cases  there  is  a  constant  reinfection  from 
a  tubercular  abscess  in  the  lung  which  perhaps  did  not  directly  communicate 
with  the  empyema  at  the  time  of  the  operation.  All  of  these  conditions, 
with  the  exception  of  the  last  one,  can  be  relieved  by  a  proper  operation, 
which  must  have  in  view  the  application  of  the  chest  wall,  or  what  is  left  of 
it,  to  the  surface  of  the  lung. 

Technique.  The  operation  to  be  chosen  must  depend  upon  the  extent 
and  location  of  the  empyema.  If  this  is  confined  to  the  lower  portion  of 
the  chest  cavity  an  excision  of  a  number  of  ribs,  beginning  with  the  seventh, 
eighth  or  ninth  and  going  upward  until  the  upper  edge  of  the  empyema  is 
reached,  will  usually  suffice.  The  thickened  pleura  should  be  removed  at 
the  same  time.    The  intercostal  arteries  should  be  ligated  in  this  operation  even 


SURGERY  OF  THE  CHEST  191 

though  no  hemorrhage  takes  place  at  the  time  of  the  operation,  or  they  should 
at  least  be  crushed  with  clamp  forceps  because  they  frequently  begin  to  bleed 
after  the  patient  has  recovered  from  shock,  unless  they  have  been  properly 
disposed  of. 

If  the  empyema  extends  up  to  a  point  above  the  level  of  the  lower  angle 
of  the  scapula  then  it  is  usually  wise  to  make  a  large  flap  of  the  chest  wall 
with  its  base  upward,  cutting  through  the  skin,  the  muscle,  the  ribs  and 
the  pleura,  and  cutting  away  a  sufficient  portion  of  the  rib  ends  to  permit 
this  flap  to  sink  into  the  cavity.  Here  again  the  intercostal  arteries  should 
be  cared  for.  It  is  usually  wise  to  apply  a  large  tampon  composed  of  aseptic 
gauze  to  the  entire  cavity  and  to  lay  the  large  flap  which  has  thus  been 
formed  upon  the  surface  of  this  tampon  and  then  to  apply  a  large  dressing 
over  it.  This  tampon  is  left  in  place  for  a  sufficient  length  of  time  to  stimu- 
late the  growth  of  vigorous  granulation  tissue  over  the  under  surface  of  this 
flap  as  well  as  over  the  surface  at  the  bottom  of  the  cavity.  After  the  tampon 
has  been  removed  the  flap  is  placed  in  this  cavity  and  permitted  to  heal  in 
place.  In  this  operation  again  it  is  often  wise  to  excise  a  thickened  pleura. 
If  the  condition  is  due  to  the  presence  of  necrotic  ribs  these  should  be  re- 
moved. If  it  is  due  to  a  reinfection  from  a  tubercular  lung  either  of  the 
methods  which  have  just  been  described  may  be  used,  but  they  are  usually 
not  followed  by  a  complete  recovery.  Occasionally  it  seems  best  to  treat 
a  chronic  empyema  by  laying  the  cavity  widely  open  by  one  or  the  other 
of  the  methods  just  described,  to  apply  a  large  tampon  to  the  cavity  thus 
exposed  and  to  reduce  this  tampon  slowly  until  the  entire  cavity  has  healed 
from  the  bottom.  In  chronic  empyema  we  should  say  that  the  m.ost  important 
point  consists  in  making  the  operation  thorough  enough. 

Even  after  this  operation  sinuses  sometimes  persist  and  these  should 
then  be  treated  by  the  injection  of  bismuth  paste  after  the  method  described 
above.  In  our  recent  experience  the  results  have  been  very  good  even  in  the 
cases  which  formerly  appeared  almost  hopeless. 

OPERATIVE    TREATMENT    OF   UNILATERAL   LUNG    TUBERCULOSIS 

BY  TOTAL  MOBILIZATION  OF  THE  CHEST  WALL,  BY  MEANS 

OF  THORACOPLASTIC  PLEURO-PNEUMOLYSIS 

The  many  attempts  by  surgical  means  (by  injection,  opening  of  the  cavity 
formed,  or  by  resection  of  the  rib,  and  part  of  the  lung)  to  cure  pulmonary 
tuberculosis  have  proven  very  unsatisfactory  because  the  slow  course  of 
healing  makes  it  a  relatively  hopeless  process. 

Murphy,  Porlanni  and  Brauer  by  artificial  pneumothorax  caused  com- 
pression of  the  lung  tissue  with  reduction  of  size  of  cavity  and  immobilization 
of  the  affected  lung  tissue. 

Brauer  states  that  adhesions  occur  in  one-fourth  of  all  cases  of  pulmo- 
nary tuberculosis,  therefore,  nitrogen,  if  introduced  between  the  pleurge,  is 
an  impossible  procedure  in  a  large  majority  of  cases.  Other  methods  of 
reducing  the  volume  of  the  lung  and  shrinking  of  cavities  in  the  lung  tissue 
have  been  attempted. 

Brauer  advocates  loosening  of  adhesions  by  surgical  interference,  and 
then  reducing  the  volume  of  lung  by  introduction  of  nitrogen  between  the 
layers  of  pleurae.  Friedrich  objects  to  this  method  because  the  pleura 
remains  thin  in  spite  of  adhesions,  and  during  manual  separation  without 
aid  of  sight  there  is  exceedingly  great  danger  of  tearing  the  lung  tissue. 
Also  because  of  the  following  complications :  Empyema  of  the  pleurge,  media- 
stinitis,  which  markedly  endanger  the  patient's  life. 


192  SURGERY  OF  THE  CHEST 

Priedrich  speaks  of  a  ease  in  which  there  was  a  large  cavity,  which,  on 
draining  of  mild  serous  pleural  exudate,  became  an  extensive  pleural  sup- 
puration, terminating  fatally  in  a  few  weeks.  , 

FRIEDRICH'S   METHOD    FOR   MOBILIZATION   OF   CHEST   WALL   BY 
MEANS  OF  TOTAL  REMOVAL  OF  BONE  WITH  PRESERVA- 
TION  OF   PLEURA   COSTALIS 

In  young  individuals  the  operation  has  a  tendency  to  produce  marked 
shrinking  of  the  lung  on  the  side  on  which  resection  is  done  and  drawing 
the  opposite  lung,  heart,  mediastinum,  diaphragm  and  clavicular  fossa  toward 
the  shrinking  lung,   which  produces  hindrances  in  the   process  of  recovery. 

For  this  reason  efforts  should  be  directed  to  prevent  this  tendency  of 
shrinking  of  an  extensively  involved  lung.  This  difficulty  is  overcome  by 
extensive  rib  resection  if  the  chest  cavity  is  allowed  to  be  closed. 

Although  most  patients  have  fever  and  considerable  expectoration,  no 
antipyretics  or  expectorants  are  given,  but  efforts  are  used  to  increase  appe- 
tite and  to  improve  the   gastro-intestinal  functions. 

Confine  patient  to  bed — give  definite  physical  and  X-ray  examination. 

Technique.  On  day  of  operation,  nothing  by  mouth  except  a  cup  of  tea 
in  the  morning.  Twenty  minutes  before  the  operation  give  hypodermic  of 
.015  to  .02  morphine  muriate. 

After  this  and  before  the  anesthetic  is  commenced  all  possible  expecto- 
ration is  encouraged  for  a  long  time  to  free  the  bronchi  and  caverns  of  secre- 
tion and  diminish  danger  of  aspiration  during  the  anesthesia. 

Place  the  patient  in  a  semi-oblique  position  with  the  body  turned  half 
over  on  well  side  with  the  arm  held  vertically  up  in  the  air. 

Disinfect  the  surgical  field  very  thoroughly  with  soap,  ether  and  alcohol. 

Incision  is  made  similar  to  that  in  Schede's  method  of  thoracoplasty  in 
empyema,  the  muscle  being  rendered  analgesic  by  Schleich's  infiltration 
method.  Then  a  flap  is  formed  by  beginning  the  incision  three  fingers'  breadth 
external  to  edge  of  the  sternum  at  the  height  of  second  or  third  rib ;  it  is 
carried  downwards  external  to  the  nipple  to  the  tenth  rib,  posteriorly  up 
again  to  the  second  dorsal  spine.  The  line  of  incision  is  varied  occasionally 
for  cosmetic  reasons. 

In  dividing  the  serratus  magnus  muscle  the  ends  of  the  serrations  are 
allowed  to  remain,  otherwise  the  whole  muscle  Avith  the  vessels  and  nerves 
is  rapidly  displaced  upward.  The  pectoralis  major  and  latissimus  dorsi  are 
deepl}'  niched  and  drawn  strongly  aside  with  retractors. 

The  bony  chest  is  now  all  exposed.  Then  with  greatest  rapidity,  the  ribs 
are  resected,  leaving  periosteum  and  intercostal  muscles  behind,  being,  how- 
ever, all  the  time  careful  not  to  puncture  the  pleura  costalis,  as  a  pneumo- 
thorax at  the  present  stage  would  greatly  endanger  the  patient,  as  a  marked 
increase  in  secretions  of  the  caverns  would  greatly  promote  suppuration. 
This  accident  is  very  much  more  easily  avoided  by  using  the  positive  or 
negative  air-pressure  apparatus  of  Brauer  or  Sauerbruch. 

After  detachment  of  the  second  to  tenth  ribs  from  the  anterior  carti- 
lages to  the  spine,  and  especially  after  the  attachments  of  second  and  tenth 
ribs  gives  way,  the  whole  lung  covered  by  the  intact  pleura  costalis  sinks 
back  toward  the  hilus,  and  in  operations  on  the  left  side,  the  heart  can  be 
seen  rising  above  the  level  of  the  lung  surface.  By  practice  such  rib  resec- 
tions as  these — removing  in  all  180  to  220  cm.  of  bone — can  be  done  in 
twenty-five  minutes. 

After  removal  of  projecting  pieces  of  intercostal  muscles,  nerves  and 
periosteum,  and  careful  hemostasis,  the  flap  of  muscle  is  carefully  approxi- 


SURGERY  OF  THE  CHEST  193 

mated  with  twenty  to  thirty  buried  catgut  sutures.  Skin  sutures  with  silk 
are  applied  and  a  thick  drainage  tube  is  inserted  along  the  spine. 

Little  general  anesthesia  required.  As  a  rule,  if  all  these  conditions 
are  carefully  attended  to  during  the  operation  the  patient  should  have  a 
good  pulse  on  leaving  the  table.  Inhalation  anesthesia  is  only  necessary 
when  rib  resection  proper  is  commenced,  provided  morphine  and  infiltration 
anesthesia  has  been  previously  used.  The  anesthetic  is  given  in  restricted 
amount  so  that  bronchial  and  laryngeal  reflexes  remain,  in  order  to  facilitate 
expectoration,  while  pain  is  not  felt.  An  experienced  anesthetist  can  do  this 
with  5  to  15  gms.  of  chloroform. 

The  heart-effect.  A  mildly  compressing  aseptic  dressing  and  bandage  is 
applied  and  patient  put  to  bed  in  a  prone-oblique  position.  The  most  impor- 
tant factor  during  the  following  hours  and  days  is  the  behavior  of  the  heart, 
which  on  account  of  change  in  volume  has  suffered  more  or  less  dislocation 
in  position  and  with  the  collapsed  lung  it  is  subjected  to  pressure  of  the  air 
on  the  opposite  side. 

The  preservation  of  the  costal  cartilages  is  important  in  preventing  dis- 
location from  acting  too  much  upon  the  heart.  The  disturbance  in  the  heart 
action  is  similar  to  that  found  associated  with  severe  contusion  of  the  thorax 
and  known  as  delirium  cordis,  characterized  by  increased  rate,  diminution 
in  size,  and  absence  of  pulse.  If  the  heart  is  energetically  stimulated  with 
digitalis  intravenously,  caffein  and  camphor  and  normal  salines  subcutane- 
ously,  the  patient  is  usually  brought  safely  through  the  dangers. 

The  course  of  wound  healing  is  usually  smooth.  In  six  to  ten  days  the 
drainage  tube  is  removed,  and  healing  by  primary  union  is  obtained. 

Dyspnea  is  the  rule  during  the  first  few  days  following  the  operation, 
due  to  the  fact  that  the  lung  on  the  opposite  side  has  to  do  all  the  work  for 
both,  besides  being  interfered  with  by  pressure  of  the  air  on  the  opposite 
lung  and  the  heart.    This  disappears  in  a  few  days. 

As  the  wound  pain  disappears  expectoration  recurs  and  is  facilitated  by 
pressing  the  hand  against  the  immobolized  side,  thus  aiding  the  removal  of 
the  contents  of  the  caverns. 

The  temperature  and  amount  of  sputum  fall  rapidly  as  soon  as  expecto- 
ration has  begun. 

In  unilateral  pulmonary  tuberculosis,  fibro-cavernous  in  type,  occurring 
in  young  and  middle-aged  persons,  with  various  degrees  of  fever,  and  in 
which  climatic,  dietetic,  and  medicinal  measures  have  been  of  no  avail  in 
staying  the  progress  of  the  disease,  the  operation  is  indicated. 

The  degree  of  temperature  and  amount  of  sputum  have  no  influence  in 
the  indications. 

(Be  conservative  in  cases  of  multiple  tuberculosis,  especially  if  associated 
with  intestinal  tuberculosis.) 

The  danger  of  the  operation  lies  in  the  increased  demands  upon  the  heart. 

ARTIFICIAL  PNEUMOTHORAX 

During  the  past  five  years  the  brilliant  suggestion  made  by  Murphy 
twenty  years  ago  to  employ  artificial  pneumothorax  in  the  treatment  of  pul- 
monary tuberculosis  has  received  much  attention,  especially  in  the  United 
States  and  in  Germany.  It  has  been  used  very  successfully  in  many  suitable 
cases  by  Dr.  Ethan  A.  Gray,  medical  superintendent  Chicago  Fresh  Air  Hos- 
pital, who  has  kindly  given  us  the  following  description  of  this  treatment. 

[Definition.  Artificial  pneumothorax  is  the  presence  of  an  innocuous  gas, 
introduced  into  the  pleural  cavity  as  a  therapeutic  measure.  The  thera- 
peutic application  of  lung  compression  depends  on  the  fact  that  tubercular 

13 


194  SURGERY  OF  THE  CHEST 

processes  of  even  severe  grade  are  often  influenced  favorably  by  the  com- 
pression produced  by  pleural  effusions.  Spontaneous  pneumothorax,  also,  has 
often  shown  marked,  though  temporarv  improvement  of  the  collapsed  lung. 

Indications.  Artificial  or  induced  pneumothorax  is  indicated,  strictly 
speaking,  in  unilateral  tuberculosis  of  the  lung.  In  fact  the  patient  must 
have  one  good,  functionating  lung,  else  he  cannot  safely  submit  to  collapse 
of  the  other.  Rudolph  Brauer  and  his  school  maintain  that,  before  lung  col- 
lapse is  indicated,  all  other  therapeutic  measures  must  have  been  tried  and 
found  wanting.  Experience  in  over  one  hundred  cases  treated  at  the  Fresh 
Air  Hospital  by  this  method  shows  that  patients  who  have  failed  to  improve 
after  a  more  or  less  lengthy  "cure"  by  medicinal,  climatic  and  hj^gienic 
means,  have  had  so  many  pleural  adhesions  that  it  was  not  possible  to  produce 
a  collapse  of  the  lung.  Again,  the  late  case  has  too  often  becom.e  actively 
bilateral,  and  much  bilateral  disease  is  a  contra-indication  to  artificial  col- 
lapse. The  early  collapse  of  the  diseased  lung  is  easy  and  is  usually  bril- 
liant in  its  results.  Early  collapse  of  a  cavernous  lung  stops  the  advance 
of  the  disease  and  checks  toxemia  by  compressing  the  lymph-spaces.  '  Tem- 
perature and  pulse  frequently  drop  rapidly  to  the  normal ;  sputum,  at  first 
more  profuse,  becomes  scanty  and  ultimately  ceases ;  cough  diminishes.  Later, 
the  diseased  portions  of  the  lung  tissue  cicatrize  and  thus  heal. 

Hemorrhage  constitutes  an  imperative  indication  for  artificial  pneumo- 
thorax, regardless  of  existing  disease  in  the  other  lung  unless  such  disease 
be  in  itself  a  menace  to  life.  High  temperature  may  be  regarded  as  a  strong 
indication  for  lung  collapse  if  the  disease  be  confined  to  one  lung. 

Contra-indications.  These  are  active  bilateral  pulmonary  disease ;  heart 
disease ;  serious  disease  of  any  other  vital  organ,  pneumoconiosis. 

Apparatus.  The  writer  uses  the  original  Murphy  type  of  apparatus,  con- 
trolled by  a  manometer  devised  by  himself.  The  apparatus  consists  of  a 
copper  cylinder  which  holds  the  nitrogen  gas  under  pressure,  a  gas  con- 
tainer (100  cc),  the  manometer  and  a  blunt  (45  degree)  point,  18-gauge 
aspirating  needle,  all  properly  connected  by  rubber  tubing ;  for  re-insufflations 
a  sharper  needle  is  used. 

Technique.  Before  proceeding  to  operation  it  is  wise  to  have  had  the 
patient  under  observation  in  a  hospital  for  at  least  thirty  days.  The  infor- 
mation thus  collected  will  be  of  great  importance. 

To  determine  the  proper  location  of  the  proposed  puncture,  careful  study 
of  the  chest  by  inspection,  percussion  and  auscultation  is  necessary. 

Inspection.     Litten's  sign,  intercostal  retraction. 

Percussion.  Normal  or  near  normal  note,  tympanic  note  of  cavity  of 
stomach ;  dullness  of  thickened  pleura,  downward  excursion  of  lung,  con- 
solidation. 

Auscultation.    Rales  close  to  stethoscope,  cavernous  respiration. 

The  Roentgen  plate  is  of  little  or  no  value  in  this  connection.  AVe  rely 
most  on  the  nearly  normal  percussion  note,  while  distrusting  auscultatory 
sounds  of  especial  clearness.  j 

The  Roentgen  screen  is  of  value  after  insufflations  and  before  refillings.    It  \ 
gives  information  as  to  the  completeness  of  collapse,  action  of  adhesions,  etc. 

One  should  be  on  guard  against  puncturing  in  the  vicinity  of  the  great 
vessels ;  the  insertions  of  the  diaphragm  should  also  be  borne  in  mind. 

After  the  patient  has  been  examined  sitting,  he  should  be  again  exam- 
ined lying  on  the  table,  a  hard  roll  or  cushion  being  under  the  thorax  so 
that  the  intercostal  spaces  will  be  separated,  and  the  site  of  puncture  raised. 
The  point  of  puncture  being  determined,  the  skin  is  painted  Avith  tincture 
of  iodine  and  a  verj''  small  incision,  not  more  than  two  or  three  millimeters 
long,  is  made  through  the  skin.     After  the  slight  bleeding  has  ceased,  the 


SURGERY  OF  THE  CHEST  195 

blunt  (18  gauge,  45  degree)  needle  is  carefully  passed  through  the  wound 
and  pushed  through  muscle  and  fascia,  until  the  parietal  pleura  gives  way 
with  a  dull  but  audible  sound ;  this  seems  to  the  operator  to  be  felt  rather 
than  heard.  (This  produces  but  slight  pain  and  does  not  require  even  local 
anesthesia.)  As  soon  as  the  needle  has  reached  the  free  pleura,  the  fact 
will  be  indicated  by  a  rise  in  the  near  column  of  the  manometer.  If  no 
movement  results  from  the  puncture,  the  needle  has  not  found  the  pleural 
sinus,  or  else  it  may  be  stopped  up  with  a  drop  of  blood  or  with  a  shred  of 
flesh.  If  no  manometric  variation  results,  the  needle  should  be  withdrawn 
for  examination.  If  clear,  it  may  be  again  introduced  in  the  attempt  to  find 
the  pleural  sinus.  Not  before  the  manometer  establishes  the  certainty  that  the 
needle  is  in  the  pleural  sinus,  should  the  gas  he  turned  on.  The  patient  must 
be  warned  not  to  breathe  deeply!  After  the  rise  in  the  near  column  has 
appeared,  the  nitrogen  is  allowed  to  flow  until  50cc.  has  been  taken;  it  is 
now  turned  off  and  the  manometer  observed;  this  will  usually  show  a  quick 
rise  to  the  same  negative  point  as  at  first.  At  the  first  operation  it  is  usually 
safe  to  give  400  to  600  cc.  of  nitrogen,  stopping  with  negative  pressure.  Excep- 
tion to  this  is  allowed  in  the  case  of  hemorrhage,  when  a  large  amount  of 
gas  is  needed  to  compress  the  bleeding  lung.  Should  the  patient  complain 
of  fullness  or  of  continued  pain,  or  of  other  distress,  or  should  the  manom- 
eter show  positive  pressure,  the  operation  should  be  terminated.  The  needle 
is  now  withdrawn,  and  the  small  wound  sealed  with  collodion,  and  a  retain- 
ing adhesive  strap  applied.  (Some  operators  use  no  dressing  and  their 
results  are  equally  good.)  The  patient  should  now  be  kept  quiet  for  twenty- 
four  hours  and  should  be  instructed  not  to  exert  himself  in  any  way;  e.  g., 
bending  over,  laughing,  straining  at  stool,  etc.  Coughing  must  be  controlled. 
Re-insufflation  is  done  in  two  days,  and  thereafter  as  often  as  the  nitrogen 
is  seen  to  be  absorbed.  Later  the  inflations  are  performed  as  seldom  as  four 
to  six  weeks  apart.  For  hemorrhage  the  lung  should  be  kept  closely  collapsed 
for  ten  to  fourteen  days  after  pneumothorax  is  produced ;  the  pneumothorax 
should  be  maintained  for  six  months.  If  the  first  puncture  proves  to  be  a 
failure,  it  is  permissible  to  make  one  or  two  more  attempts  at  the  same 
sitting.  Careful  study  of  the  chest  sometimes  reveals  a  more  favorable  site 
for  puncture. 

Complications  and  dangers. — Air  or  gas  embolism.  This  accident  is  caused 
by  the  entrance  of  a  quantity  of  gas  into  a  vein.  If  the  bubbles  of  gas  are 
carried  into  the  vital  centers  of  the  brain,  death  occurs  in  a  short  time. 
Phenomena  of  gas  embolism,  as  observed  by  European  operators,  are  sudden 
dizziness  and  loss  of  consciousness  ••  frequently  Jacksonian  convulsions,  hemi- 
plegia, cutaneous  congestion,  respiratory  failure,  death. 

Embolism  may  occur  in  either  the  primary  or  in  the  later  insufflations. 
It  is  said  to  have  occurred  even  when  the  strictest  precautions  have  been 
observed.  !1         !    '    I. 

A  study  of  the  mechanism  of  air  embolism  has  given  rise  to  certain 
important  rules: 

1.  Never  urge  the  patient  to  breathe  deeply  in  the  search  for  the  pleural 
sinus. 

2.  Never  turn  on  the  gas  before  the  manometer  shows  by  negative  pres- 
sure indication  that  the  needle  opening  is  in  the  pleural  sinus. 

3.  Always  operate  on  the  recumbent  patient,  the  point  of  puncture  being 
uppermost.  (Saugmann  suggests  that  air  bubbles  will  have  difficulty  in 
reaching  the  lower-lying  brain,  thus  diminishing  the  danger  of  embolus.  Be 
this  as  it  may,  my  own  experience  in  nearly  900  insufflations  without  accident, 
all  made  on  the  recumbent  patient,  would  seem  to  bear  out  Saugmann 's 
idea.) 


196 


SURGERY  OF  THE  CHEST 


4.  Never  move  the  needle  about  in  the  wound.  If  the  sinus  is  not  found 
after  slowl}^  introducing  and  -withdrawing  the  needle,  and  the  lumen  of  the 
latter  be  found  clear,  the  attempt  should  be  given  up  at  that  point,  and 
perhaps  for  that  time. 

Embolus  has  occurred  before  the  gas  has  been  turned  on,  the  gas  in  the 
tubing  having  been  sufficient  to  cause  the  accident. 

Emphysema.  This  occurs  within  a  few  hours  of  the  operation  and  may- 
be painful  and  uncomfortable  but  it  is  in  no  wise  dangerous;  the  gas  maj'- 


A  Large  Ulcer  of  the  Chest  Wall  Arising  from  Typhoid  Osteojiyelitis  of  the  Eibs,. 
Treated  by  Dressings  of  Dakin  's  Solution  and  Finally  by  Thiersch  Skin  Grafts, 
which  Are  Shown  in  Place  in  the  Photograph. 


infiltrate  the  subcutaneous  tissue  over  the  whole  side,  down  to  the  hip,  up 
the  neck  and  down  the  arm.    It  absorbs  in  a  few  days. 

Over-inflation.  This  manifests  itself  by  rapid  heart,  dyspnea,  difficult 
deglutition,  due  to  pressure  on  the  gullet  and  by  extension  of  the  pneumo- 
thorax to  the  opposite  side  of  the  sternum  and  spine.  A  hypodermic  of 
morphia  (gr.  %)  will  quiet  the  situation  for  a  few  hours,  by  which  time 
the  organs  will  have  ad.justed  Ihemselves  and  some  of  the  gas  will  have 
absorbed.  If  the  patient's  condition  becomes  alarming  it  is  a  simple  matter 
to  withdraw  some  of  the  gas. 


SUPtGEKY  OF  THE  CHEST 


197 


Pneumonia.  This  or  any  other  serious  complication  in  the  "good"  lung 
calls  for  abandonment  of  the  collapse  treatment.  It  may  even  be  necessary  to 
deflate  the  pneumothorax  in  order  to  relieve  the  patient's  respiratory  embar- 


P. 


't. 


•4f 


*--«^ 


m^j 


I 


k 


"^m 


>    .    ^ 


/ 


Shovtixg  How  the  Skix  Grafts  Are  Protected  by  Wire  Xettixg. 


rassment.  I  have  seen  a  pneumonia  patient  recover  under  these  circum- 
stances.   Broncho-pneumonias,  particularly  after  hemorrhage  are  usually  fatal. 

Prognosis.  This  depends  on  the  stage  and  condition  in  which  the  case  is 
when  taken  for  treatment.  If  one  selects  those  in  whom  there  is  no  hint  of 
bilateral  involvement,  or  those  whose  disease  is  not  far  advanced,  the  results 
will  be  most  satisfactory.  If  cases  are  selected  which  require  careful  watch- 
ing, which  are  likely  to'have  lighting  up  of  foci  in  the  other  lung,  fewer  will 
show  such  complete  cures  as  those  in  the  previous  category. 

Again,  cases  which  receive  gas  in  an  ultimun  refugium,  will  not  be  fruitful 
of  good  results. 


198  SURGERY  OF  THE  CHEST 

In  the  first  and  second  groups  many  patients  will  be  cured  and  returned  to 
work.  In  the  last  group,  life  will  be  prolonged ;  exacerbation  of  disease  often 
occurs  in  the  other  side  and  ends  any  further  attempts  with  pneumothorax. 

Our  experience  with  patients  of  all  disease  types  at  the  Fresh  Air  Hospital, 
convinces  me  that : 

(a)  Pneumothorax  should  be  practised  earlj^  * 

(b)  It  should  be  offered  to  the  suitable,  far-advanced  cases  on  the  chance 
of  saving  one  here  and  there. 

Ability  to  work.  The  patient  with  a  collapsed  lung  is  able  to  do  consider- 
able work.  For  example,  we  have  our  patients  working  as  chauffeur,  elevator 
conductor,  stationery  engineer,  painter,  delivery  driver,  house-keepers,  clerks, 
railway  conductor  and  others. 

Duration  of  treatment.  This  varies ;  some  cases  do  well  with  a  collapse 
maintained  only  a  short  time  (six  months),  others  require  treatment  of  a  year 
to  two  years.  Saugmann  reports  a  case  of  a  woman  who  returned  for  her  gas 
during  six  years.  Expansion  of  the  lung  and  gradual  obliteration  of  the 
pleural  sac  occurs  in  a  fair  percentage  of  cases  and  thus  automatically  ter- 
minates the  treatment.    Many  of  these  cases,  so  terminated,  do  very  well.] 

TUBERCULOSIS  OF  THE  RIBS 

This  condition  may  occur  primarily  or  secondarily.  In  either  case  it  results 
in  abscess  formation  and  later  in  the  formation  of  sinuses  leading  down  to 
diseased  bone.  It  is  occasionally  possible  to  secure  healing  by  making  a  free 
incision  over  the  middle  of  the  diseased  rib  reflecting  the  periosteum  and  curet- 
ting away  the  diseased  tissue,  but  usually  nothing  short  of  excision  of  the  rib 
will  suffice. 

ACTINOMYCOSIS 

The  positive  sign.  In  the  United  States  empyema  caused  by  an  infection 
with  the  ray  fungus  is  not  so  very  uncommon  and  should  constantly  be  borne 
in  mind  as  one  of  the  possibilities,  especially  as  the  treatment  must  be  entirely 
different  in  case  actinomycosis  is  present.  This  condition  can  be  recognized  by 
the  presence  of  little  yellowish  fiakes  in  discharge  from  the  empyema  which 
contain  the  characteristic  ray  fungus,  easily  demonstrated  by  microscopical 
examination. 

The  curative  value  of  potassium  iodide  and  the  dosage.  In  cases  suffering 
from  actinomycosis  it  is  important  to  bear  in  mind  the  fact  that  this  disease  is 
curable  by  the  administration  of  very  large  doses  of  iodide  of  potash.  Small 
doses  are  of  little  benefit.  It  seems  necessary  to  saturate  the  blood  thoroughly 
with  this  drug  in  order  to  destroy  the  parasite.  The  method  which  we  have 
found  most  useful  consists  in  the  administration  of  sixty  to  ninety  grains  of 
iodide  of  potash  in  a  glass  of  warm  milk,  followed  by  a  pint  of  hot  water,  three 
times  a  day,  preferably  at  6  a.  m.  and  at  2  and  10  p.  m.,  in  order  to  have 
the  periods  eight  hours  apart.  In  this  way  the  drug  may  be  given  in  these 
large  doses  without  causing  any  marked  disturbance.  It  is  used  for  three 
days  in  succession;  then  the  patient  is  permitted  to  rest  for  quite  one  week, 
after  which  the  administration  is  again  repeated.  After  about  six  weeks  of 
treatment  these  cases  usually  recover  perfectly  unless  an  undrained  abscess 
be  present.  In  such  event  some  of  the  parasites  seem  to  remain  where  the  drug 
does  not  reach  them  and  from  that  point  reinfection  may  take  place;  conse- 
quently it  is  wise  to  repeat  the  treatment  a  number  of  times  after  permitting 
the  patient  to  rest  for  a  month  or  two,  when  he  has  arrived  at  what  is  con- 
sidered a  complete  cure.    This  precaution  is  especially  needful  in  patients  who 


SURGERY  OF  THE  CHEST  199 

live  at  a  distance  so  that  they  cannot  be  kept  under  observation  conveniently. 
We  lost  one  patient  evidently  because  this  precaution  was  neglected.  In 
a  second  case  in  which  the  disease  was  located  in  the  neck  the  patient  returned 
after  one  year  with  a  recurrence,  complicated  with  an  edema  of  the  larynx 
which  nearly  proved  fatal.  Renewed  treatment  with  ninety  grains  of  potas- 
sium iodide  again  relieved  the  patient,  who  has  now  been  well  for  ten  years. 
After  being  apparently  well  the  remedy  was  given  for  three  days  each  month 
for  six  months. 

Purity  of  the  drug'.  It  is  to  be  borne  in  mind  that  small  doses  of  potassium 
iodide  are  absolutely  useless  in  the  treatment  of  this  disease.  Furthermore, 
it  is  of  the  greatest  importance  to  use  a  preparation  of  potassium  iodide  which 
is  absolutely  pure.  Most  of  this  drug  as  obtained  in  the  market  seems  not  to 
be  perfectly  pure,  and  while  in  our  experience  ninety  grains  can  always  be 
given  when  the  pure  drug  is  used  many  patients  cannot  take  even  much  smaller 
doses  of  the  ordinary  drug. 

ABSCESS  OF  THE  LUNG 

Physical  signs.  Following  pneumonia  or  an  infection,  such  as  puerperal, 
in  some  other  part  of  the  body,  an  abscess  in  the  lung  not  connected 
with  the  pleural  cavity  may  occur.  This  may  communicate  with  a  bronchus 
and  may  evacuate  itself  thereby  from  time  to  time,  or  it  may  remain  circum- 
scribed within  the  lung  tissue.  It  is  relatively  easy  to  recognize  this  condition 
if  the  abscess  cavity  communicates  with  a  bronchus,  because  its  filling  and 
emptying  can  be  observed.  If  it  is  near  the  costal  surface  of  the  lung  it  may 
be  recognized  by  percussion,  giving  much  the  same  sound  that  is  obtained 
upon  percussion  over  the  surface  of  the  liver.  If  the  abscess  is  not  at  the  edge 
of  the  lung  resonance  will  be  observed  above,  below,  and  to  each  side  of  it, 
giving  the  impression  of  a  circumscribed  space  filled  with  fluid.  Its  presence 
usually  gives  rise  to  an  abnormal  temperature,  which  frequently  reaches  104, 
105  and  106°  Fahrenheit. 

In  the  more  serious  cases  a  considerable  portion  of  one  lobe,  or  the  entire 
lobe,  may  become  gangrenous  from  the  presence  of  an  infarct. 

One  of  the  larger  vessels  may  be  completely  obstructed  by  a  thrombus  so 
that  a  considerable  portion  of  lung  tissue  becomes  necrotic.  In  these  cases 
there  is  always  a  very  marked  odor  as  soon  as  the  products  of  this  decompos- 
ing lung  tissue  are  expectorated.  The  expectorated  material  usually  has  the 
character  of  thin,  sanguineous  pus,  which  is  quite  characteristic. 

Danger  of  lung  collapse  and  its  prevention.  The  rational  treatment  must, 
of  course,  consist  in  the  evacuation  of  the  abscess  externally.  There  is,  how- 
ever, one  great  danger  in  this  operation  resulting  from  the  fact  that  in  order 
to  approach  the  abscess  the  pleural  cavitj''  must  be  opened,  and  if  an  adhesion 
does  not  exist  between  the  pulmonary  and  the  costal  pleura  the  lung  is  likely 
to  collapse.  This  condition  frequently  results  in  the  death  of  the  patient,  and 
in  order  to  guard  against  it  the  surgeon  should  be  prepared  to  inflate  the  lung 
through  a  tube  inserted  into  the  larynx,  constructed  so  that  its  end  will  fit 
tightly  between  the  vocal  cords.  Its  top  should  be  connected  with  bellows  by 
means  of  which  the  collapsed  lung  may  be  inflated.  The  apparatus  known  as 
the  Fell-0'Dwyer  is  very  simple  and  efficient,  and  this,  or  some  other  positive 
pressure  apparatus  should  always  be  procured  whenever  the  operation  here 
mentioned  is  undertaken. 

Technique.  A  U-shaped  incision  should  be  made  over  the  area  covering 
the  abscess  and  the  flap  turned  back,  exposing  two  or  three  ribs.  Portions 
four  inches  in  length  of  at  least  two  ribs  should  be  resected  with  great  care, 
in  order  not  to  penetrate  the  costal  pleura  until  sufficient  space  has  been 


200  SURGERY  OF  THE  CHEST 

secured  to  repair  the  mischief  which  might  occur  from  the  sudden  collapse  of 
the  lung.  After  this  area  has  been  laid  bare  the  portion  of  lung  opposite  may 
be  grasped  by  means  of  fine  volsellum  forceps  through  the  costal  pleura,  or 
fine  stitches  of  catgut  may  be  passed  through  the  costal  pleura  and  the  adjoin- 
ing lung  at  several  points,  or  an  apparatus  for  inflating  the  lung  may  be 
applied  and  the  lung  filled  with  air  by  compressing  the  bellows,  and  then  the 
costal  pleura  may  be  opened  and  the  lung  sutured  to  this  opening,  or  it  may 
be  sutured  to  folds  of  iodoform  gauze  which  are  drawn  over  the  edge  in  the 
opening  in  the  costal  pleura  so  that  the  lung  cannot  be  retracted. 

A  method  which  has  been  very  satisfactory  consists  in  suturing  with  cat- 
gut pieces  of  wet  gauze  to  the  parietal  pleura  and  lung  around  the  edge  of  the 
opening  before  the  pleura  is  opened;  the  moist  gauze  prevents  the  entrance 
of  air  and  consequently  pneumothorax  cannot  occur.  The  abscess  is  then  best 
entered  by  means  of  the  actual  cautery,  because  the  opening  thus  made  will 
enlarge  when  the  eschar  caused  by  the  burn  becomes  separated. 

Upon  introducing  the  finger  into  this  cavity  bands  will  be  found  to  pass 
through  it  which  the  surgeon  atempts  to  break  down  in  order  to  reduce  the 
entire  space  into  one  cavity.  These  bands  frequently  contain  large  blood 
vessels  and  it  is  consequently  best  to  apply  hemostatic  forceps  to  them  and  to 
cut  between  these.  The  cavity  may  be  drained  by  inserting  a  few  strands  of 
gauze ;  then  the  wound  is  dressed  as  in  the  operation  for  the  relief  of  empyema. 

In  case  the  abscess  of  the  lung  approaches  the  pleura,  adhesions  between  the 
pulmonary  and  the  costal  pleurae  have  usually  formed  so  that  there  is  no 
danger  from  the  formation  of  pneumothorax,  but  it  is  never  safe  to  operate  in 
these  cases  without  being  prepared  to  find  no  adhesions  present.  Plere  again 
a  large  dressing  is  indicated,  and  it  is  wise  not  to  permit  the  external  wound 
to  heal  too  soon  after  the  operation. 

GUNSHOT  AND  STAB  WOUNDS  OF  THE  CHEST 

Hemorrhage.  In  the  treatment  of  gunshot  or  stab  wounds  of  the  chest  it 
is,  first,  important  to  determine  whether  there  is  dangerous  bleeding  from  the 
intercostal  vessels  or  from  the  internal  mammary  artery.  The  former  can 
easily  be  exposed,  clamped  and  ligated.  The  latter,  being  located  near  the 
sternum  between  the  costal  cartilages  and  the  pleura,  is  in  a  position  in  which 
it  is  difficult  to  ligate  without  fear  of  causing  pneumothorax  by  opening  the 
pleura.  The  fact  that  this  vessel  is  given  off  from  the  subclavian  artery  makes 
the  hemorrhage  very  formidable,  and  the  further  fact  that  it  is  located  behind 
the  costal  cartilages  makes  a  hemorrhage  into  the  pleural  cavity  more  likely 
than  an  external  hemorrhage.  In  case  of  bleeding  from  the  internal  mammary 
artery  it  is  necessary  to  remember  that  the  costal  cartilage  can  be  easily  cut 
with  an  ordinary  scalpel  and  that  the  external  wound  is  of  no  importance,  con- 
sequently a  large  external  wound  should  be  made  over  the  costal  cartilage  of 
the  next  rib  above  the  point  of  injury,  this  cartilage  should  be  carefully  cut 
away  for  a  distance  of  at  least  an  inch  over  the  point  at  which  it  crosses  the 
artery,  and  then  a  fine  stitch  should  be  passed  around  the  artery  and  tied. 
The  danger  from  trying  to  perform  this  operation  through  a  small  external 
wound  is  very  mucli  greater  than  it  is  if  ample  space  be  secured  by  making 
a  large  one. 

The  hemorrhage  from  these  two  sources  having  been  disposed  of  the  next 
important  point  is  to  secure,  as  nearly  as  possible,  complete  rest  of  the  chest 
walls.  This  can  best  be  accomplished  by  applying  a  plaster-of-Paris  jacket 
extending  from  the  lower  border  of  the  ribs  up  over  both  shoulders.  The 
patient  will  immediately  begin  to  breathe  by  using  the  diaphragm  alone  and 
the  irritable  hacking  cough  will  in  most  cases  subside,   and  therefore  the 


SURGERY  OF  THE  CHEST  201 

patient  will  stop  pumping  blood  from  the  lung  tissue  into  his  pleural  cavity. 
If  empyema  follows  through  an  infection  caused  by  the  injury  it  should  be 
treated  according  to  the  method  which  has  already  been  detailed. 

Do  not  probe:  Apply  chest  splint.  This  point  should  be  borne  in  mind 
above  all  things — that  under  no  conditions  should  a  wound  of  the  thorax  be 
examined  with  a  probe,  because  probing  is  one  of  the  chief  sources  of  infection. 
If  plaster-of -Paris  is  not  available,  or  if  the  patient  does  not  seem  sufficiently 
strong  to  bear  its  application,  a  protecting  cast  may  be  constructed  in  a  few 
minutes  by  winding  long  strips  of  rubber  adhesive  plaster,  from  two  to  three 
inches  in  width,  about  the  entire  chest,  beginning  at  the  border  of  the  ribs 
and  working  upwards  until  the  whole  chest  and  shoulders  are  covered.  Sev- 
eral layers  of  this  plaster  may  be  applied  to  advantage.  It  is  surprising  how 
quickly  a  patient  who  has  not  been  able  to  rest  for  a  moment  on  account  of 
the  irritation  due  to  the  motion  of  his  chest  walls,  will  become  quiet  and  fall 
asleep  after  one  or  the  other  of  these  jackets  has  been  applied.  Cases  which 
have  so  far  advanced  that  the  danger  of  new  hemorrhage  is  over,  but  in  which 
the  blood  in  the  pleural  cavity  is  not  absorbed,  should  be  aspirated  through  a 
trocar  or  drained  by  open  incision  or  treated  like  an  empyema. 

Value  of  the  chest  splint.  The  same  treatment  with  rubber  adhesive 
plaster  strips  acts  quite  as  beneficially  in  patients  with  severe  injury  to  the 
ribs  due  to  contusion  A  man  sixty-two  years  of  age  was  caught  under  an  up- 
turned vehicle  and  rolled  between  the  ground  and  the  vehicle,  resulting  in  a 
number  of  ribs  being  broken  at  various  places.  AVhen  we  saw  him  at  his  home 
twelve  hours  later  his  pulse  w^as  imperceptible,  he  was  severely  cyanosed  and 
only  with  great  difficulty  could  he  gasp  for  a  little  air.  He  was  almost  uncon- 
scious from  exhaustion  although  his  head  had  not  been  injured.  As  soon  as 
the  rubber  adhesive  plaster  cast  had  been  applied  the  patient  began  to  breathe 
regularly  and  quietly,  although,  of  course,  entirely  with  his  diaphragm;  his 
pulse  came  back,  beating  180  per  minute.  "Within  an  hour  it  had  been  reduced 
below  100  per  minute.  He  became  perfectly  conscious  at  once  and  made  a 
thorough  recovery.    AVe  have  seen  many  similar  though  less  severe  cases. 

PNEUMOTHORAX 

If  the  wound  in  the  chest  wall  has  been  sufficient  to  admit  a  quantity  of  air 
the  lung  will  become  compressed  and  a  pneumothorax  will  be  formed.  All 
that  is  required  for  the  relief  of  this  condition  is  the  closure  of  the  external 
wound,  unless  there  has  been  a  complete  collapse  of  the  lung,  in  which  event 
the  lung  should  first  be  distended  by  means  of  iniiation  before  the  opening  in 
the  chest  wall  is  closed,  or  the  opening  may  be  closed  and  the  air  contained  in 
the  chest  cavity  may  be  aspirated  by  a  pump  through  a  trocar.  If,  however, 
air  is  forced  into  the  pleural  cavity  from  the  lung  itself  by  the  injury  of  the 
lung  tissue  then  it  may  become  necessary  to  make  a  rib  resection,  to  grasp  the 
injured  point  of  the  lung  with  forceps  to  draw  it  to  the  external  wound  and 
there  to  attach  it,  after  the  manner  described  in  the  operation  for  abscess  of 
the  lung.  The  wound  in  the  lung,  however,  is  usually  so  small  that  it  closes 
spontaneously,  or  it  is  so  large  that  the  patient  succumbs  before  the  surgeon 
has  an  opportunity  to  secure  relief  by  an  operation. 

The  Fell  bellows.  Dr.  George  Fell  has  invented  a  form  of  negative  pressure 
bellows  attached  to  a  bell  which  can  be  placed  over  the  opening  in  the  chest 
wall  and  by  means  of  which  a  vacuum  may  be  secured  which  will  immediately 
remove  any  air  that  has  entered  the  chest  cavity  through  an  opening  in  the 
chest  wall.  This  vacuum  can  be  maintained  indefinitely  until  the  wound  in  the 
chest  wall  has  closed  spontaneously,  or  sutures  may  be  inserted  before  the  air- 
pump  has  been  applied,  and  when  all  of  the  air  has  been  withdrawn  from  the 


202  SURGERY  OF  THE  CHEST 

pleural  cavity  these  sutures  are  drawn  tense  and  then  tied,  thus  permanently 
closing  the  chest  cavity  against  recurrence  of  pneumothorax. 

The  Sauerbruch  cabinet  and  other  methods.  Many  other  forms  of  appar- 
atus have  been  invented  during  the  past  few  years  for  the  purpose  of  con- 
trolling especially  that  form  of  pneumothorax  that  is  produced  intentionally 
during  operations  upon  intrathoracic  organs.  This  idea  was  brought  forward 
successfully  and  effectively  first  by  Sauerbruch,  who  introduced  a  negative 
pressure  cabinet  in  which  the  surgeon  and  the  body  of  the  patient  was  placed 
while  the  patient's  head  projected  into  the  outer  air  through  an  opening  lined 
with  a  perforated  rubber  sheet,  the  perforation  fitting  snugly  about  the 
patient's  neck.  By  pumping  air  out  of  the  chamber  containing  the  body  a 
sufficient  negative  difference  of  pressure  could  be  produced  to  cause  the  air 
which  entered  the  lungs  through  the  trachea  at  a  higher  pressure  to  distend 
the  lungs  to  a  sufficient  extent  to  prevent  the  formation  of  pneumothorax  when 
the  chest  wall  was  opened.  The  degree  of  pressure  can  be  accurately  con- 
trolled by  an  assistant. 

Brauer  produced  the  same  effect  of  overpressure  by  leaving  the  body  of 
the  patient  in  the  atmosphere  of  the  operating  room  and  placing  the  head  in 
a  cabinet  into  which  air  is  being  pumped  in  sufficient  quantity  to  produce  a 
sufficient  degree  of  pressure  to  prevent  the  formation  of  pneumothorax  when 
the  chest  wall  is  opened.  Robinson  has  perfected  a  most  excellent  apparatus 
for  the  same  purpose,  in  which  the  cabinet  containing  the  high  pressure  air 
is  sufficiently  large  to  accommodate  the  anesthetist  at  the  same  time.  Willy 
Meyer  has  produced  a  still  more  ingenious  apparatus  that  can  be  changed  from 
a  negative  to  a  positive  pressure,  and  vice  versa,  in  a  moment. 

All  of  these  forms,  however,  are  extremely  expensive  and  complicated  and 
only  available  in  large  institutions. 

The  same  overpressure  effect  has  been  produced  by  Fell  with  an  extremely 
simple  mechanism  that  may  be  obtained  at  a  very  small  cost  and  which  has 
been  used  in  a  large  number  of  cases  with  absolutely  satisfactory  results.  It 
consists  of  a  compound  bellows  furnishing  a  uniform  stream  of  air  which  is 
forced  into  the  lungs  through  an  accurately  fitting  mask  applied  over  nose 
and  mouth,  or  through  an  intubation  or  a  tracheotomy  tube.  Melzer  and 
Carrel  have  produced  the  same  result  by  pumping  air  into  the  lungs  with 
ordinary  bellows  through  a  catheter  filling  the  trachea  to  two-thirds  of  its 
size  and  extending  almost  but  not  quite  to  the  bifurcation  of  the  trachea. 

We  have  seen  all  of  these  methods  in  use  but  have  used  only  the  Fell  appar- 
atus in  our  own  practice  and  its  simplicity  and  effectiveness  has  impressed  us 
strongly  in  its  favor.  Theoretically,  however,  there  seems  to  be  no  doubt  but 
that  the  apparatus  of  Willy  Meyer  is  at  the  present  time  the  most  perfect  for 
the  control  of  pneumothorax  during  intrathoracic  operations. 

The  chest  wall  in  all  of  these  cases  must  of  course  be  definitely  closed 
before  the  apparatus  is  discarded  after  any  of  these  operations. 

HYDROTHORAX 

Hydrothorax  is  so  easily  recognized  by  physical  examination  that  it  is 
scarcely  worth  while  to  discuss  it.  It  is  so  common  in  its  occurrence  that  it 
rarely  reaches  the  hands  of  the  surgeon.  The  accumulation  of  fiuid  in  the 
pleural  cavity  may  absorb  spontaneously  or  it  may  be  withdrawn  by  aspira- 
tion. Only  a  part  of  the  fluid  should  be  withdrawn  at  one  time.  Many  author- 
ities prefer  to  withdraw  but  a  few  ounces  and  to  depend  upon  absorption  for 
the  removal  of  the  remaining  portion,  which  usually  occurs  after  a  few  ounces 
have  been  aspirated.     Other  surgeons  prefer  to  remove  a  considerable  pro- 


SURGERY  OF  THE  CHEST  203 

portion  of  the  fluid.    There  is  no  doubt  but  that  it  is  wise  never  to  remove  the 
entire  amount  present. 

TUMORS  OF  THE  CHEST 

Of  tumors  of  the  chest  which  are  interesting  in  a  surgical  way  only  those 
due  to  the  presence  of  hydatids,  actinomyces  and  syphilis,  and  dermoid  cysts, 
need  to  be  mentioned.  Sarcomata,  carcinomata  and  endotheliomata  occur  but 
are  not  interesting  surgically  (i.e.,  call  for  no  particularly  different  form  of 
treatment)  except  from  a  diagnostic  standpoint.  Hydatid  cysts  most  fre- 
quently occur  through  perforation  of  the  diaphragm  on  account  of  infection 
from  hydatids  of  the  liver.  This  condition  is  treated  in  the  same  manner  as 
empyema.  Actinomycosis  has  already  been  discussed.  Gummata  are  treated 
by  means  of  internal  medication  if  the  condition  is  recognized.  Dermoid  cysts 
are  enucleated,  the  same  precautions  being  taken  to  prevent  collapse  of  the 
lung  that  were  described  in  connection  with  the  treatment  of  pulmonary 
abscess. 

Lympho-sarcomata  are  of  especial  interest  because  their  usual  location 
about  the  diaphragm  makes  the  differentiation  between  this  condition  and 
empyema  difficult  at  times. 

MEDIASTINAL  ABSCESS 

This  affection  is  recognized  by  the  symptoms  of  weight  and  pain  in  the 
retro-sternal  region.  The  pain  is  increased  especially  upon  drinking,  cough- 
ing, and  upon  pressure.  There  is  frequently  a  swelling  over  the  surface  of 
the  sternum.  The  condition  is  treated,  when  diagnosed,  after  the  same  man- 
ner as  abscesses  in  general.  An  opening  is  cut  in  the  sternum  and  the  pus 
permitted  to  evacuate.  The  cavity  is  then  drained  by  means  of  strands  of 
gauze  carried  to  the  bottom  of  the  abscess. 

TUBERCULOSIS  OF  THE  STERNUM 

The  sternum  may  be  removed  in  part  or  entirely  for  tuberculosis,  precisely 
as  one  would  remove  a  tuberculous  rib.  If  possible  the  costal  attachment 
should  not  be  disturbed.  The  operation  is  not  especially  dangerous,  because 
there  is  in  these  cases  a  sufficient  support  on  account  of  the  presence  of  con- 
nective tissue  which  has  formed  behind  the  sternum  as  a  result  of  the  long- 
continued  inflammation  which  preceded  the  destruction  of  this  bone. 

INFECTIONS  OF  THE  MAMMARY  GLAND 

Methods  of  production.  These  occur  most  commonly  through  abrasions  of 
the  nipple  during  nursing.  The  mouth  of  the  child  may  contain  the  infectious 
micro-organisms  or  they  may  be  upon  the  surface  of  the  nipple  when  the  child 
is  applied,  or  fissures  may  occur  and  the  staphylococci  which  are  ordinarily 
found  in  the  skin  may  cause  the  infection.  The  arrangement  of  the  lymph 
channels  and  milk  ducts,  and  the  connective  tissue  structure  of  the  breast, 
radiating  in  every  direction  from  the  nipple  as  a  center,  account  for  an  infec- 
tion following  one  or  more  of  these  structures  and  becoming  localized  at 
any  distance  from  the  nipple.  It  may  then  progress  to  the  formation  of 
abscesses  varying  in  size  and  location. 

Upon  examination  one  or  more  points  of  induration  are  commonly  found. 


204  SURGERY  OF  THE  CHEST 

The  tissues  over  these  points  are  edematous  and  there  is  pain  upon  pressure. 
If  the  infection  is  advanced  there  is  also  redness  or  fluctuation  present.  The 
acuteness  of  the  attack  will  differentiate  this  condition  from  tumors. 

Aside  from  the  history  of  lactation  there  may  also  be  one  of  traumatism,  or 
there  may  be  evidences  of  an  infection  in  some  other  portion  of  the  body. 

Rest  and  methods  of  prevention.  Early  in  the  occurrence  of  an  infection 
of  the  breast  it  is  fretjuently  possible  to  cause  it  to  subside  by  securing  absolute 
rest.  The  blood  supply  of  this  portion  of  the  body  is  so  plentiful  that  an 
extensive  amount  of  infectious  material  may  be  entirely  absorbed  if  the  prog- 
ress of  the  infection  is  not  favored  by  motion.  The  patient  should  therefore 
be  placed  in  bed  and  the  breast  supported  by  strapping,  preferably  with  rubber 
adhesive  straps  that  have  been  carefully  applied,  or  with  an  accurately  applied 
flannel  or  elastic  rubber  bandage.  If  the  infection  is  quite  slight  then  a  large, 
moist,  antiseptic  dressing  covered  with  rubber  protective  tissue  will  probably 
best  favor  absorption,  the  patient  of  course  being  kept  at  rest.  Further  infec- 
tion should  be  prevented  by  thoroughly  washing  the  nipples  before  and  after 
each  nursing  and  by  applying  some  antiseptic  substance,  such  as  ointment  con- 
taining boric  acid  or  some  substance  like  tincture  of  benzoin  or  tincture  of 
myrrh,  which  has  a  protective  effect  on  account  of  its  resinous  character. 
Solutions  of  rubber  have  been  prepared  which  may  be  applied  to  the  nipple 
after  it  has  been  carefully  dried,  and  which  will  serve  as  an  excellent  protec- 
tive covering.  Above  all  things  the  nipples  should  be  kept  clean  at  all  times 
and  should  be  carefully  washed  just  before  and  just  after  nursing.  The  child's 
mouth  should  also  be  washed  in  order  to  prevent  infection  from  this  source. 
The  milk  should  be  pumped  out  of  such  a  breast  at  regular  intervals,  care 
being  taken  not  to  cause  anj^  traumatism  of  the  infected  tissues  by  the  manipu- 
lations which  are  thus  necessitated. 

Technique.  If  the  infection  progresses  to  the  formation  of  circumscribed 
abscesses  these  should  be  incised  freely  and  drained  by  the  insertion  of  gauze 
or  gutta  percha  tissue  drains  and  a  sufficiently  large  dressing  should  be  applied 
to  absorb  all  of  the  discharge.  Personally,  we  prefer  a  moist  antiseptic  dress- 
ing consisting  of  one  part  of  alcohol  with  two  parts  of  saturated  solution  of 
boric  acid  for  this  purpose. 

It  is  important  that  the  incisions  should  be  made  in  a  manner  so  as  to 
cause  them  to  radiate  from  the  nipple  in  order  to  prevent  cutting  off  any  of 
the  ducts  which  branch  from  this  point.  Rest  in  bed  and  support  by  means 
of  dressings  and  bandages  should  be  insisted  upon,  because  this  will  prevent 
any  formation  of  further  abscesses  by  progressive  infection  after  the  primary 
focus  has  once  been  opened. 

CHRONIC  MASTITIS 

Chronic  mastitis  is  the  result  of  a  deep-seated  infection  with  pus  microbes 
of  moderate  virulence.  This  condition  may  give  rise  to  the  diagnosis  of  tumor 
of  the  breast. 

The  application  of  a  large  glass  bell  attached  to  an  air-pump,  according  to 
Bier's  method,  once  each  day  over  a  breast  which  has  been  incised  for  the 
relief  of  abscess  greatly  facilitates  the  patient's  recovery.  The  negative  pres- 
sure must,  of  course,  be  carefully  regulated  to  prevent  unnecessary  pain. 

In  protracted  cases  that  come  under  the  care  of  a  surgeon  a  long  time  after 
the  abscess  has  been  lanced,  so  that  only  a  sinus  is  left,  we  have  had  satisfac- 
tory results  by  applying  Bier's  vacuum  pump  and  later  injecting  the  sinus 
with  Beck's  bismuth  paste. 


SURGERY  OF  THE  CHEST 


205 


TUMORS  OF  THE  BREAST 


Dangers  of  even  simple  growths.  The  most  common  benign  tumor  in  the 
breast  is  the  fibro-adenoma.  Pure  fibromata  and  pure  adenomata  are  exceed- 
ingly rare.  Aside  from  these  are  found  retention  cysts,  lipomata,  enchrondro- 
mata,  and,  very  rarely,  hydatid  cysts.  All  of  these  tumors  are  likely  to  occur 
in  young  patients.  They  are  movable  and  are  not  accompanied  with  retrac- 
tion of  the  nipple.  They  give  rise  to  no  pain  and  rarely  grow  to  any  consid- 
erable size.  AYe  have,  however,  observed  a  large  number  of  cases  in  which 
such  tumors  remained  perfectlj^  harmless  until  the  patient's  age  exceeded  forty 
years,  when  the  condition  changed,  at  first  usually  so  slowly  that  the  patient 
hardly  was  aware  of  the  alterations,  then  definite,  stinging  pains  were  felt 
and  later  a  slight  degree  of  induration.  The  history  would  then  show  that 
when  the  patient  came  under  observation  it  was  plain  from  the  external  exam- 
ination that  we  had  to  do  at  best  with  an  adeno-carcinoma,  although  in  these 


Chronic  Cystic  Mastitis  of  the  Eight  Breast.  MAiiiiECTOiiY  7  Years  Previous  for  a 
Similar  Condition  on  the  Left  Side.  Treatment — Total  Excision  op  the  Eight 
Breast. 

cases  of  long  standing  there  could  be  no  doubt  but  that  they  had  started  as 
perfectly  benign  growths.  We  have  encountered  many  of  these  which  were 
hopelessh'-advanced,  inoperable  carcinomata  when  they  came. 

Accepting  the  general  statement  that  there  is  a  tendency  in  all  tumors  of 
the  breast,  with  the  exception  of  lipomata,  to  become  malignant  later  in  life, 
it  consequently  seems  wise  to  remove  every  benign  tumor  in  this  location  as 
early  as  possible  after  it  has  been  discovered.  The  operation  is  safe,  does  not 
inconvenience  the  patient,  and  may  relieve  her  of  a  very  serious  danger. 

Carcinomata  are  the  most  common  of  all  malignant  tumors  of  the  breast. 
Epitheliomata  are  less  frequent;  sarcomata  still  less  frequent  in  their  occur- 
rence. Paget 's  nipple,  which  is  a  dermatitis  with  a  tendency  to  the  develop- 
ment of  epithelioma,  is  not  very  common  in  this  country. 

Physical  signs.  Heredity  is  supposed  to  be  an  important  element  in  the 
history  of  malignant  tumors  of  the  breast.  The  growth  itself  may  have  existed 
in  the  form  of  a  benign  tumor  for  a  considerable  period  of  time  (as  has  just 
been  pointed  out),  or  it  may  appear  in  the  form  in  which  it  persists.  Its  loca- 
tion is  more  commonly  directly  underneath  the  nipple,  but  it  may  occur  in  any 


206 


SURGERY  OF  THE  CHEST 


portion  of  the  breast.  At  first  it  is  movable,  but  later  it  becomes  adherent  to 
the  skin  or  to  the  fascia  of  the  pectoralis  major  muscle.  One  of  the  signs 
which  has  been  recognized  as  characteristic  is  the  retraction  of  the  nipple  due 
to  the  contraction  of  the  underlying  trabeculae  of  the  connective  tissue.  This 
condition,  however,  is  present  only  if  the  tumor  is  near  the  nipple.  If  the 
growth  is  slow  the  tumor  is  hard ;  if  it  is  rapid  it  may  be  either  soft  or  hard 
upon  pressure. 


Amputation  of  Breast. 

The  incision  extends  in  front  of  the  auxiliary  space  and  includes  a  considerable  amount  of 
skin  overlying  the  mammary  gland. 


Sooner  or  later  the  disease  progresses  along  the  lymph  channels,  forming 
secondary  nodules  in  the  lymph  glands,  first  in  the  axillary  region,  second,  in 
the  infra-clavicular  and  later  in  the  supra-clavicular  region.  Still  later,  lymph 
channels  extending  toward  the  skin  are  invaded  and  the  latter  is  presently 
destroyed,  giving  rise  to  an  open  ulcer. 

A  dangerous  custom.  At  this  point  we  wish  to  state  emphatically  that 
observations  have  convinced  us  that  an  enormous  amount  of  harm  is  done  to 
patients  suffering  from  incipient  carcinoma  of  the  breast  by  the  careless  manip- 


SURGERY  OF  THE  CHEST 


207 


ulation  of  this  organ  by  the  physician  or  surgeon  making  the  examination, 
or  by  any  other  persons  handling  the  part.  AYe  believe  that  many  times  "we 
have  seen  the  growth  of  carcinoma  of  the  breast  largely  increased  in  this 
manner,  AVe  believe  also  that  we  have  observed  cases  in  which  secondary 
infection  of  the  lymphatics,  and  even  of  the  liver,  was  caused  by  frequent 
manipulation.  During  the  past  few  years  we  have  encountered  a  number  of 
patients  suffering  from  this  disease  who  were  treated  by  severe  massage  at 
the  hands  of  osteopathic  healers,  in  whom  there  was  an  enormous  increase  in 
the  growth  of  the  tumor  in  a  relatively  short  time,  and  in  several  cases  a  sec- 
ondary infection  of  the  liver.  In  the  same  m^anner  an  infection  with  carcinoma 
may  extend  into  the  chest,  following  the  lymphatics  which  accompany  the 
internal  mammary  artery;  or  the  opposite  breast  may  be  invaded  because  of 
the  lymphatic  connection  betw^een  the  two  organs ;  or  it  may  extend  along  the 
intercostal  lymphatics  into  the  spine,  giving  rise  to  paraplegia  dolorosa. 


Outline  of  Ixcisiox,  Maeked  with  a  Scratch  Stroke  of  the  Knife. 
(Jabez  Jackson.) 


If  there  is  any  doubt  as  regards  the  diagnosis  of  carcinoma  of  the  breast 
we  believe  that  in  every  case  it  is  much  better  for  the  patient  to  have  the  organ 
removed  at  once,  and  with  the  same  care  that  would  be  exercised  if  its  malig- 
nancy were  positively  known,  rather  than  to  temporize  until  the  condition 
becomes  so  plain  that  the  surgical  treatment  is  usually  useless  and  the  patient 
therefore  in  a  hopeless  state. 

Age  incidence.  Carcinoma  containing  an  abundance  of  connective  tissue 
is  more  likely  to  occur  in  those  advanced  in  years,  and  the  malignancy  of  this 
form  is  not  so  great  as  that  in  carcinoma  with  but  a  slight  amount  of  connec- 
tive tissue.  The  latter  form  of  carcinoma  is  more  likely  to  occur  in  young 
persons,  usually  under  forty  years  of  age.  Sarcoma  is  also  more  prone  to 
occur  at  this  age,  while  epithelioma,  starting  in  the  skin  and  penetrating  the 
deeper  tissues,  is  more  apt  to  develop  in  patients  over  forty  years  of  age ; 
hut  if  is  not  safe  to  depend  upon  the  age  in  making  a  differential  diagnosis  be- 
tween 'benign  and  malignant  tumors  of  the  hreast. 


208 


SURGERY  OF  THE  CHEST 


To  differentiate  between  chronic  mastitis  and  tumors,  it  will  be  found  that 
when  the  breast  is  pressed  against  the  chest  wall  with  the  hand  in  mastitis 
the  enlargement  is  of  uniform  consistency,  in  tumors  there  is  a  nodular  arrange- 
ment of  the  thickening. 


Exposure  and  Division  of  the  Pectokalis  Major. 
(Jabez  Jackson.) 

Operative  principles.  There  are  a  few  important  principles  which  should 
be  remembered  in  the  removal  of  a  carcinoma  of  the  breast : 

1st.  The  direction  in  which  carcinomatous  infection  progresses  from  the 
primary  seat  of  disease,  and  consequently  the  direction  in  which  recurrence 
is  likely  to  take  place,  should  be  noted.  Bearing  this  in  mind,  it  is  important 
to  remove  a  large  portion  of  skin  overlying  the  tumor,  even  though  the  tumor 
itself  be  quite  small. 

2nd.     The  subcutaneous  fat  should  be  removed  for  a  great  distance. 

3rd.  All  the  tissues  to  be  removed  should  be  included  in  a  continuous 
mass  to  prevent  the  infection  of  any  portion,  during  the  progress  of  the  opera- 
tion, from  an  exposed  part  of  the  malignant  growth. 

4th.  All  the  soft  tissues  down  to  the  ribs,  to  a  point  up  under  the  clavicle, 
as  far  as  possible  into  the  axilla,  including  the  overlying  skin,  the  superficial 
and  deep  fascia,  the  fat,  the  entire  breast  enclosed  in  its  capsule,  the  pectoralis 
major  and  minor  muscles,  and  all  the  axillary  and  subclavian  fat,  together 
with  the  lymphatic  glands  contained  in  it,  should  be  removed  in  one  mass. 

5th.     The  patient  must  be  protected  against  too  great  a  loss  of  blood. 

6th.  The  important  subclavian  and  axillary  vessels  and  the  pleura  must 
not  be  injured. 

Lines  of  incision  and  technique.  Many  incisions  have  been  planned  and  for 
each  certain  advantages  are  claimed.  It  is  probably  of  little  importance  which 
is  chosen.  A  very  good  exposure  may  be  obtained  by  making  a  curved  wound, 
beginning  at  a  point  four  inches  below  the  axilla  along  the  anterior  surface  of 
the  deltoid  muscle,  extending  across  the  chest  at  a  sufficient  distance  from 
tJie  tumor  to  insure  safety  ag'ainst  infection,  usually  six  to  ten  centimeters 


( 


SUEGERY  OF  THE  CHEST 


209 


from  the  nipple  will  suffice,  then  carrying  this  incision  around  the  breast  at 
a  uniform  distance  from  the  nipple  and  extending  upwards  to  the  original 
point,  as  shown  in  plate.  The  most  satisfactory  incision  for  the  removal  of 
extensive  carcinomata  in  our  experience  is  the  one  introduced  by  Rodman, 
as  shown  in  plate,  because  it  secures  at  once  the  complete  removal  of  all 
the  infected  skin,  secures  a  free  approach  to  the  diseased  tissue,  and  provides 
for  the  perfect  closure  of  the  wound. 

After  grasping  the  bleeding  vessels  with  pressure  forceps  the  skin  around 
the  edges  of  this  incision  should  be  dissected  up,  the  underlying  fat  being  left 
attached  to  the  chest  wall.  This  dissection  should  be  carried  a  sufficient 
distance  back  to  include  all  the  diseased  tissue,  at  least  five  centimeters  in  each 
direction  in  ordinary  cases.  The  incision  is  then  carried  down  to  the  ribs 
alono-  the  border  of  this  area  and  the  entire  mass,  as  described  before,  is 


Isolation  and  Division  op  the  Pectoralis  Major. 
(Jabez  Jackson.) 

dissected  up  to  a  point  approaching  the  axillary  vein,  care  being  always  taken 
to  grasp  the  bleeding  vessels  with  pressure  forceps.  Then  the  attachment  of 
the  pectoralis  major  to  the  humerus  is  severed  and,  later,  the  lower  attach- 
ment of  the  pectoralis  minor  is  also  divided.  Between  these  two  attachments 
it  is  wise  to  grasp  the  vessels  with  two  pairs  of  forceps,  to  cut  between  these 
and  to  ligate  the  stump  toward  the  axillary  side.  The  distal  ends  of  the 
sub-clavian  and  axillary  veins  are  now  dissected  free,  all  the_  small  branches 
issuing  from  the  veins  being  caught  in  two  pairs  of  hemostatic  forceps.  Cut 
between,  and  ligate  the  end  toward  the  axillary  vein  at  once  for  fear  of  tearing 
the  latter  with  the  forceps.  By  proceeding  slowly  with  this  portion  of  the 
work  it  is  possible  in  a  comparatively  short  time  to  lay  bare  the  entire  vein 
without  doing  any  harm  to  this  structure.  The  dissection  is  then  carried  down- 
ward through  the  axillary  space,  and  the  entire  mass  cut  away  from  its 
posterior  attachment,  the  bleeding  points  having  been  caught  carefully  during 
each  step  of  the  operation  so  that  the  entire  amount  of  blood  lost  will  be 
slight. 

It  is  important  that  the  tumor  be  not  manipulated  roughly  because  it  seems 


210 


SURGERY  OF  THE  CHEST 


likely  that  carcinomatous  cells  could  be  loosened  from  the  substance  of  the 
growth  if  careless  handling  or  pressure  be  allowed. 

If  there  still  remain  small  portions  of  fat  attached  to  the  axillary  structures 
they  can  be  removed  with  great  rapidity  and  perfect  safety  by  grasping  them 
in  a  piece  of  moist  gauze  held  in  the  hand  and  drawing  this  gauze  over  these 
structures,  permitting  them  to  slip  through  the  grasp  of  the  hand  holding  the 
gauze.  In  this  manner  these  small  portions  of  fat  containing  minute  lymphatic 
glands  may  be  removed  more  perfectly  and  with  much  greater  ease  and  rapid- 
ity than  by  actual  dissection.  All  the  bleeding  vessels  that  have  been  caught, 
from  which  bleeding  has  not  been  stopped  permanently  by  the  pressure  of  the 


Pectoralis  Muscle  Severed  from  Beneath,  and  Perforating  Branch  of  the 

Internal  Mammary  Caught  -with  Forceps. 

(Jabez  Jackson.) 


hemostatic  forceps,  should  be  ligated.  "We  make  use  of  fine  catgut  for  this 
purpose. 

For  a  number  of  years  we  have  followed  the  plan  of  preserving  the  distal 
end  of  the  pectoralis  minor  muscle  and  cutting  away  only  the  proximal  half 
of  it  for  the  purpose  of  covering  the  axillary  structures.  After  thoroughly 
removing  all  the  fat  and  lymph  nodes  in  the  axilla,  the  cut  end  of  the  distal 
portion  of  the  pectoralis  minor  muscle  is  sutured  to  the  intercostal  muscles 
so  that  this  remnant  of  the  pectoralis  minor  muscle  protects  these  structures. 

The  area  exposed  is  so  enormous  that  a  certain  amount  of  serous  discharge 
must  be  expected,  and  consequently  we  believe  it  is  wise  to  insert  one  or  two 
moderate-sized  drainage  tubes  through  an  opening  in  the  posterior  flap,  as 
shown  in  plate.  The  wound  is  then  united  by  means  of  interrupted  tension 
sutures,  for  which  silk  or  silk-worm  gut  may  be  employed,  and  coaptation 


SURGERY  OF  THE  CHEST 


211 


sutures  for  the  purpose  of  adjusting  the  edges  of  the  wounds.    If  these  edges 
cannot  be  adjusted  without  applying  a  great  amount  of  tension  it  is  much 


Method  of  Ixsertiox  of  Figuee-of-eight  Coaptatiox  Sutures. 
(Jabez  Jackson.) 


Flap  Sutured  in  Place  with  Drainage  Tube  Inserted. 
(Jabez  Jackson.) 

better  to  leave  a  space  between  the  edges  of  the  wound  and  to  cover  this  by 
means  of  Thiersch's  skin-grafts. 


212 


SURGERY  OF  THE  CHEST 


A  large  dressing  is  applied  to  the  breast  in  order  to  approximate  the  skin 
flaps  to  the  chest  wall  by  means  of  gentle  pressure.  The  arm,  to  the  elbow,  is 
included  in  the  bandage,  but  should  not  be  tied  down  sufficiently  firm  to  make 
the  patient  uncomfortable. 


Amputation  of  Breast  for  Carcinoma. 

a  cut  end  of  pectoralis  major  muscle;  h  cut  end  of  pectoralis  minor  muscle;  c  brachial 
plexus  of  nerves;  e  axillary  vein. 

Rodman's  method.  The  incision  described  above,  which  was  first  intro- 
duced by  Jackson,  is  so  satisfactory  that  it  may  not  seem  necessary  to  describe 
other  methods,  but  the  authors  have  used  the  method  of  Rodman  during  the 
past  five  years  in  a  large  number  of  cases  and  have  found  it  even  more  satis- 
factory, consequently  it  may  be  interesting  to  add  a  short  description  thereof. 

An  incision  is  made  through  the  skin  from  a  point  near  the  middle  of  the 


SURGERY  OF  THE  CHEST 


213 


clavicle  directly  backward,  being  careful  to  remain  far  enough  away  from  the 
breast  to  be  beyond  every  portion  of  the  growth. 

From  this  incision  a  second  one  is  carried  above  and  a  third  one  below  the 
breast  and  directed  toward  the  sternum,  where  they  meet,  then  an  incision  is 


Amputation  of  Breast  foe  Carcinoma. 
The  wound  has  been  sutured  and  drainage  tubes  are  in  place. 

carried  downward  from  this  point  directly  over  the  upper  end  of  the  rectus 
abdominis  muscle,  whose  anterior  fascia  is  removed  because  it  may  contain 
infected  lymph  nodes.  The  flaps  are  reflected  as  described  above.  The  axilla 
is  exposed  by  dissecting  up  the  flap  formed  by  the  first  incision. 

Then  the  breast,  together  with  the  pectoralis  major  and  minor  muscles  and 
all  the  axillary  fat  and  lymph  nodes,  is  removed  in  the  manner  already 
described. 


214 


SURGERY  OF  THE  CHEST 


The  advantage  of  this  operation  lies  in  the  fact  that  after  healing  there  is 
no  sear  in  the  skin  of  the  axilla,  and  in  the  removal  of  the  fascia  of  the  upper 
end  of  the  rectus  abdominis  muscle. 

DISSEMINATED  LENTICULATE  CARCINOMA  OF  THE  SKIN  OF  THE 
BREAST.   (CANCER  EN  CUIRASSE.) 

This  form  occurs  not  infrequently  as  a  direct  cancerous  infection  of  the 
lymphatics  of  the  skin  after  an  operation  for  the  removal  of  primary  car- 
cinoma of  the  breast.  The  infection  may  also  occur  directly  from  the  primary 
carcinoma. 


Cancer  en  cuirasse. 

The  French  name,  indicating  the  appearance  of  a  coat  of  mail,  is  so  char- 
acteristic that  one  can  scarcely  fail  in  making  the  diagnosis.  Near  the  region 
of  this  complication  the  skin  is  thickly  studded  with  nodules,  usually  red  in 
color,  and  radiating  from  this  area  to  a  considerable  distance  will  be  found 
smaller  lenticular  nodules.  A  few  times  we  have  observed  this  form  of 
secondary  carcinoma  originating  in  the  stitch  mark,  indicating  that  the 
carcinomatous  tissue  was  directly  inoculated  in  the  skin  from  the  deeper  por- 
tions. It  is  likely  that  the  subcutaneous  fat  contained  the  carcinoma  cells  in 
these  instances  and  that  these  cells  were  carried  by  the  needle  into  the  over- 
lying lymphatics  of  the  skin  proper. 

The  surgical  treatment  must  be  entirely  prophylactic.    By  removing  a  large 


SUEGERY  OF  THE  CHEST 


215 


portion  of  the  overlying  skin,  together  with  the  carcinoma  of  the  breast,  it  is 
likely  that  this  complication  will  be  prevented. 

During  the  past  few  years  a  number  of  these  apparently  hopeless  cases  have 
recovered  after  the  use  of  the  Roentgen  rays.  Whether  such  recovery  is  to  be 
permanent  or  temporary  remains  to  be  seen.  In  our  own  experience  no  patient 
has  ever  presented  herself  for  treatment  of  this  condition  to  whom  we  could 
promise  any  surgical  relief.  "Whether  the  excision  of  a  large  portion  of  skin 
and  underlying  fat  would  give  relief  in  cases  coming  under  treatment  very 
early  we  are  unable  to  state. 


Scar  Following  Complete  Mammectomy  for  Carcinoma  of  the  Breast. 

Recurrence.  In  order  to  prevent  a  recurrence  it  is  important  to  bear  in 
mind  everything  that  has  been  said  above  concerning  the  technic,  but  espe- 
cially that  in  patients  suffering  from  very  small  tumors  the  operation  must 
be  made  quite  as  extensively  as  in  the  presence  of  a  larger  growth,  because 
only  in  this  manner  is  it  possible  to  prevent  them  from  suffering  from  hope- 
less recurrences,  for  in  these  cases  it  frequentlj^  happens  that  a  few  car- 
cinoma cells  find  their  way  into  the  lymph  canals  and  are  caught  by  lymph 
nodes  at  a  considerable  distance,  and  if  these  latter  are  not  removed  during 
the  primary  operation  a  recurrence  is  of  course  inevitable.  The  recent  anatom- 
ical studies  upon  fresh  cadavers  by  Moreau  has  given  us  still  further  reasons 
for  being  very  careful  in  following  the  lymph  nodes.  He  has  demonstrated 
that  the  axillary  fascia  is  a  continuation  of  the  middle  cervical  fascia,  begin- 


216 


SURGERY  OF  THE  CHEST 


Recurrent  Carcinoma  of  the  Breast  Following  Excision  of  a  Part  of  the  Tumor. 
Axillary  Metastases  Present.  Treatment — Complete  Mammectomy.  At  "A"  Is 
Seen  Incision  of  Incomplete  Operation. 


Rodman's  Amputation  of  the  Breast  for  Carcinoma. 
(We  are  indebted  to  Dr.  D.  Guthrie  of  Sayre,  Pa.,  for  these  six  drawings.) 
Eepresents  the  typical  incision. 


SURGERY  OF  THE  CHEST 


217 


ning  at  the  posterior  surface  of  the  clavicle  and  passing  downward  behind 
the  subclavian  muscle   down  to   the  pectoralis   minor  muscle,   then  passing 


l^Bi 

■ 

HI 

^■■MP^' 

A. 

^^1 

i 

HI 

^^^'r- 

^^ 

^4m 

■ 

g^ 

0 

1 

^1 

k 

m 

^9F 

^,.^ 

n^^-^ 

1 

jMN^ 

p 

^ 

-rtS 

^^f? 

w 

"*^ 

1 

Ilii^^ 

.1|k 

m 

rt 

i 

1' 

^B 

iriwmimr-  g- 

!■■ 

11 

Hi 

^ 

»MHFO'''^''.iP^SBBil 

The  section  of  the  pectoralis  major  muscle. 


Shows  the  pectoralis  major  muscle  turned  up  and  the  finger  inserted  underneath  the 
pectoralis  minor  muscle  represented  by  the  letter  D.  A,  represents  the  pectoralis  major  muscle; 
B,  the  acromiothoracic  artery;  C,  claAdcular  portion  of  pectoralis  major;  D,  pectoralis  minor; 
E,  the  long  thoracic  artery.     [See  follovring  page.] 

behind  this  into  the  axilla,  where  it  forms  the  base  of  the  axilla.  Then  it 
turns  slightly  upAvards  in  front  of  the  latissimus  dorsi  and  teres  major  muscles 
and  becomes  attached  to  the  lateral  edge  of  the  scapula. 

It  is  plain  that  this  arrangement  leaves  the  space  quite  free  for  progressive 
carcinomatous  infection  after  the  axilla  has  once  been  involved. 


218 


SURGERY  OF  THE  CHEST 


Shows  the  axillary  structures  perfectly  exposed.  A,  pectoralis  major  muscle;  B,  pectoralis 
minor;  C,  clavicular  portion  of  pectoralis  major;  E,  long  thoracic  artery  and  vein;  F,  nerve 
of  Bell;  G,  alar  thoracic  artery  and  vein;   H,  subscapular  artery,  vein  and  nerve. 


Shows  the  entire  excision  completed.  A,  sheath  of  rectus  muscle;  B,  acroiniothoracic 
artery;  C,  long  thoracic  artery;  D,  clavicular  portion  of  pectoralis  major  not  removed;  E, 
axillary  vein;  F,  alar  thoracic  artery;  G,  subscapular  muscle;  H,  subscapular  artery  and 
vein;  I,  latissimus  dorsi  muscle;  J,  subscapular  nerve;  K,  nerve  of  Bell. 


SURGERY  OF  THE  CHEST 


219 


Shows  the  manner  in  which  the  wound  is  closed  without  any  scar  tissue  in  the  axilla. 


Basal-Celled  Epithelioma  of  the  Breast.    Age  of  Patient,  52  Years.  Treatment — Com- 
plete Mammectomy. 


220 


SURGERY  OF  THE  CHEST 


EPITHELIOMA  OF  THE  BREAST 

Primary  epithelioma  of  the  nipple  is  not  very  uncommon.  Its  progress 
is  likely  to  occur  more  rapidly  into  the  deep  structures  than  into  the  sur- 
rounding skin.  Even  at  a  very  early  stage  there  has  usually  been  a  secondary 
infection  of  the  tissues  of  the  breast  itself.  In  a  few  instances  in  which 
the  disease  seemed  to  be  very  limited  we  have  found  that  there  was  an  infec- 
tion not  only  of  the  tissues  of  the  breast,  but  also  of  the  axillary  lymphatic 
glands. 

The  conditions  just  described  will  of  course  indicate  that  the  same  plan 
of  treatment  must  be  followed  which  has  been  outlined  in  connection  with 


Lipoma  of  the  Breast. 

carcinoma  of  the  breast  proper.  If  anything  less  is  done  the  progress  of  the 
disease  will  only  be  increased  and  the  patient  is  likely  to  succumb  sooner  than 
she  would  if  nothing  at  all  were  done  in  a  surgical  way ;  in  fact,  with  a  thor- 
ough removal  of  the  skin,  the  breast,  the  pectoralis  major  and  minor  muscles 
and  the  axillarj-  and  subclavian  lymphatics  and  fat,  these  patients  have  a 
chance  to  recover  permanently. 

SARCOMA  OF  THE  BREAST 


The  diagnosis  of  sarcoma  of  the  breast  can  not  usualh^  be  made  positively 
until  the  tumor  has  been  removed.  This  is  of  little  importance,  inasmuch  as 
the  same  operation  must  be  performed  which  would  be  done  in  the  presence 
of  a  carcinoma. 


SURGERY  OF  THE  CHEST  221 

TUBERCULOSIS  OF  THE  BREAST 

Patients  suffering  from  tuberculosis  of  the  breast  usually  give  a  history 
of  tuberculosis  in  some  other  portion  of  the  body,  most  commonly  pulmonary. 

In  many  cases  there  is  the  history  of  an  injury;  in  others  the  history  of 
localized  tuberculosis  of  the  lymph  glands  in  other  portions  of  the  body. 
The  history,  together  with  the  general  appearance  of  the  patient  and  the 
fact  that  the  axillary  glands  are  usually  enlarged,  while  the  examination  of 
the  breast  itself  gives  the  impression  one  obtains  in  manipulating  a  chronic 
mastitis  or  a  multiple  fibro-adenoma,  usually  suffices  to  make  a  fairly  positive 
diagnosis  of  tuberculosis.  There  are,  however,  cases  in  which  it  is  not  possible 
to  differentiate  this  condition  from  carcinoma.  If  the  disease  has  existed  for 
a  more  or  less  extended  period  of  time  some  portion  of  the  growth  will  have 
usually  undergone  caseous  degeneration,  giving  rise  to  the  sensation  of  fluctua- 
tion, which  will  also  serve  as  a  diagnostic  sign.    The  nipple  is  usually  retracted. 

The  treatment  should  consist  in  the  removal  of  the  entire  breast,  together 
with  the  lymphatic  glands  and  fat  of  the  axilla.  It  is  not  necessary  here  to 
disturb  the  pectoralis  major  or  minor,  or  the  fascia  covering  the  former. 
Unless  there  is  present  a  mixed  infection  of  some  broken  down  portion  of 
the  tumor  it  is  usually  safe  to  close  the  entire  wound  without  drainage. 

MILK  FISTULA 

Following  an  incision  into  the  breast  for  the  drainage  of  an  abscess,  or 
following  the  spontaneous  opening  of  an  abscess  of  the  breast,  and  occa- 
sionally following  traumatism,  a  fistula  remains  connected  with  one  of  the 
milk  ducts  which  secretes  milk  either  constantly  or  intermittently. 

In  recent  eases  these  fistulfe  can  sometimes  be  cured  by  cauterizing  the 
external  opening,  or  by  curetting  the  fistula,  or  by  making  a  longitudinal 
incision  through  the  fistula,  but  in  chronic  cases  a  careful  excision  of  the 
false  passage  is  necessary  in  order  to  secure  permanent  relief. 

MOBILIZING  THE  CHEST  WALL  FOR  RELIEF  OF  PERICARDIAL 

ADHESIONS 

Pericardial  adhesions  to  chest  wall  cause  a  condition  which  is  at  once 
most  distressing  to  the  patient  and  exhausting  to  the  heart  itself,  as  with 
each  contraction  the  heart  makes  an  unsuccessful  eft'ort  to  pull  itself  awaj' 
from  its  fibrous  attachment  to  the  chest  wall,  and  with  each  expansion  it  is 
pushed  by  the  adhesion  against  this  rigid  wall. 

Mobilizing  this  rigid  wall  then  over  the  area  occupied  by  the  heart  must 
necessarily  bring  great  comfort  to  the  patient,  and  must  at  the  same  time 
reduce  greatly  the  wear  and  tear  upon  the  heart  itself.  This  may  be  accom- 
plished by  the  following  operation : 

Technique.  A  curved  incision  is  made  just  below  the  left  mammary  gland 
from  fifteen  to  twenty  cm.  long;  the  breast  is  reflected  upward  and  the  fourth, 
fifth  and  sixth  ribs  are  laid  bare.  The  middle  of  the  area  to  which  the 
pericardium  is  adherent  is  determined  by  the  impact  of  the  heart  and  each 
rib  is  excised  to  the  length  of  twelve  cm.  so  that  a  vertical  line  drawn  through 
the  center  of  the  area  of  impact  would  bisect  each  fragment  of  rib  removed. 

In  making  this  excision  if  possible  all  of  the  periosteum  should  be  removed 
with  the  ribs,  so  as  to  prevent  their  regeneration. 

The  skin  and  muscle  flap  is  then  replaced,  two  small  gutta  percha  tissue 
or  fine  rubber  tube  drains  are  inserted,  and  the  wound  is  closed. 

The   relief  is   almost   instantaneous,   because   the   soft  wall   which   takes 


222  SURGERY  OF  THE  CHEST 

the  place  of  the  rigid  costal  wall  yields  readily  with  the  motion  of  the  heart, 
whose  pulsation  consequently  becomes  slower,  with  an  improved  character 
and  quality  of  the  contraction,  and  a  rapid  building  up  of  the  patient's 
general  condition. 

PERICARDIAL  EFFUSION 

"While  this  can  hardh'  be  classed  as  a  surgical  disease,  yet  the  surgeon 
is  often  called  upon  for  relief  when  it  has  become  distressing,  and  so  it  may 
be  proper  to  contribute  a  few  words  to  the  subject  at  this  point. 

The  heart  is  usually  sufficiently  far  awaj^  from  the  chest  wall,  because 
of  the  presence  of  a  large  amount  of  pericardial  fluid,  to  prevent  injury 
Avhen  the  trocar  is  inserted  for  the  purpose  of  partial  withdrawal  of  fluid. 

The  puncture  should  be  made  in  the  fifth  or  sixth  intercostal  space  in 
the  left  mammillary  line  in  large  accumulations,  which  are  the  only  ones  that 
require  this  operation. 

It  is  best  to  use  a  trocar  two  mm.  thick  with  a  very  sharp  but  short 
pointed  stillette.  The  distance  to  which  this  is  to  be  plunged  into  the  chest 
must  be  determined  by  holding  the  point  of  the  index  finger  against  the 
trocar  so  that  it  cannot  be  forced  in  any  farther  than  contemplated.  The 
stillette  is  then  withdrawn  and  enough  fluid  is  permitted  to  escape  to  give 
immediate  relief,  but  not  enough  to  shock  the  patient  or  to  permit  the  heart 
to  touch  the  pericardium. 

The  fluid  should  be  withdrawn  very  slowly,  with  repeated  interruptions, 
especially  if  there  is  any  irregularity  in  breathing  or  in  the  heart's  action 
during  the  progress  of  the  operation. 

The  canula  should  be  held  in  such  a  direction  that  there  is  no  danger 
of  the  surface  of  the  heart  striking  against  it  and  becoming  lacerated.  The 
withdrawal  of  a  portion  of  the  fluid,  usually  from  one  to  four  ounces,  is 
likely  to  stimulate  absorption  of  the  remaining  portion,  but  if  this  does  not 
occur  the  operation  must  be  repeated  whenever  a  sufficient  amount  has  reaccum- 
ulated  to  give  rise  to  much  distress. 

In  introducing  the  trocar  the  intercostal  vessels  should  be  avoided  by 
remaining  near  the  upper  margin  of  the  rib,  below  the  puncture  point,  and 
avoiding  the  lower  edge  of  the  upper  rib.  The  fourth,  fifth  or  sixth  inter- 
costal space  should  be  chosen,  according  to  the  position  of  the  fluid. 

PERICARDIAL  SUPPURATION 

The  condition  just  described  may  be  followed  by  suppuration  in  the 
pericardial  space.  In  this  event  it  seems  reasonable  to  expect  that  the  two 
per  cent,  formaline  in  glycerine  treatment  introduced  by  Murphy  for  the 
cure  of  empyema  of  the  chest  should  give  satisfactory  results. 

Simple  aspiration  without  free  drainage  has  given  such  absolutely  unsat- 
isfactory results  that  this  should  never  be  practised,  and  in  case  of  diagnosis 
of  pericardial  effusion  and  demonstration  of  the  presence  of  pericardial  sup- 
puration upon  aspiration  the  radical  operation  should  be  done  at  once. 

The  operation  for  the  relief  of  this  condition  consists  in  the  removal  of 
ten  cm.  of  the  fourth  or  fifth  rib  over  the  most  prominent  portion  of  the 
pus  sac,  placing  gauze  into  this  wound  for  twenty-four  to  forty-eight  hours 
and  then,  making  a  crucial  incision  through  the  middle  of  the  exposed  area, 
the  pus  is  permitted  to  drain  through  a  pledget  of  gauze  or  one  composed 
of  folded  rubber  tissue. 


SURGERY  OF  THE  CHEST  223 

We  have  not  had  an  opportunity  to  use  Beck's  bismuth  paste  in  these 
cases  in  the  after-treatment,  but  it  seems  plainly  indicated  where  healing 
does  not  take  place  promptly  after  drainage  has  been  installed. 

In  cases  in  which  the  intercostal  tissues  are  edematous  at  the  time  of 
the  operation  it  is  not  necessary  to  postpone  the  incision  if  the  patient's  con- 
dition is  such  as  to  make  an  immediate  evacuation  of  the  pus  desirable,  because 
there  is  no  danger  in  these  cases  from  the  occurrence  of  hydrothorax,  owing 
to  the  fact  that  the  existing  inflammatory  process  has  produced  the  necessary 
adhesions  to  prevent  this. 

WOUNDS  OF  THE  HEART 

It  is  important  to  be  familiar  with  some  method  of  exposing  the  heart 
in  case  one  should  encounter  a  patient  suffering  from  a  stab  or  gunshot 
wound  thereof.  We  have  never  had  an  opportunity  to  operate  in  one  of  these 
cases  and  consequently  cannot  speak  from  personal  experience  with  any 
method,  but  the  subject  is  so  important  and  any  surgeon  is  so  likely  to  be  in 
a  position  in  which  he  must  act  promptly,  that  we  will  give  the  method 
advocated  by  Eocher  because  it  has  the  advantage  of  great  simplicity  and 
at  the  same  time  fills  all  of  the  demands  met  by  any  or  all  of  the  many  more 
complicated  methods.  It  secures  an  easy,  rapid  approach  to  the  heart,  gives 
an  excellent  exposure  of  the  organ  and  guards  against  the  formation  of 
pneumothorax.  In  hospital  practice  this  should  further  be  guarded  against  by 
the  use  of  one  of  the  various  devices  that  have  already  been  described;  but 
most  of  these  patients  are  so  seriously  injured  that  the  time  necessary  to 
adjust  an  apparatus  would  probably  be  sufficient  to  permit  the  patient  to 
die  from  hemorrhage  unless  the  Fell  or  the  Melzer  type  happened  to  be 
available. 

The  entire  chest  should  be  quickly  saturated  with  compound  tincture  of 
iodine,  which  should  always  be  at  hand.  The  surgeon  should  put  on  sterile 
rubber  gloves  without  stopping  to  scrub  his  hands. 

If  no  tincture  of  iodine  is  available  the  skin  should  be  scrubbed  rapidly 
with  warm  water  and  soap  with  a  piece  of  gauze,  then  with  alcohol,  then  ether. 

An  incision  ten  cm.  long  is  made  from  the  middle  of  the  sternum  over 
the  sixth  costal  cartilage  to  the  bony  part  of  the  sixth  rib,  cutting  the  attach- 
ment of  the  rectus  abdominis  muscle.  The  pectoralis  major  is  loosened  from 
its  attachment  to  the  upper  border  of  the  rib  and  the  attachment  of  the  inter- 
costal muscles  is  loosened  both  above  and  below  with  the  knife.  The  peri- 
chondrium on  the  posterior  surface  is  loosened  with  a  periosteal  elevator. 
The  sixth  costal  cartilage  is  now  cut  at  the  point  of  its  attachment  to  the 
sternum  and  that  to  the  seventh  costal  cartilage. 

The  internal  mammary  artery  and  vein  are  seen  at  a  point  one  cm.  to  the 
left  of  the  sternum ;  they  are  clamped,  cut  and  ligated. 

Underneath  this  point  the  sternal  attachment  of  the  transverse  thoracic 
muscle  is  cut,  and  the  muscle,  together  with  the  pleura,  is  pushed  to  the 
left,  which  exposes  the  dense  fibrous  pericardium. 

If  the  heart  is  compressed  by  the  accumulation  of  blood  in  the  pericardium 
this  sac  is  opened  at  once,  otherwise  the  following  steps  are  taken : 

If  the  wound  is  in  the  upper  portion  of  the  heart  the  incision  is  carried 
upward  to  the  fourth,  third  or  second  intercostal  space.  Here  a  lateral 
incision  is  made  eight  cm.  long  through  the  pectoralis  major  muscle  to  the 
upper  margin  of  the   costal   cartilage   and  rib.     The  intercostal  muscle   is 


224  SURGERY  OF  THE  CHEST 

loosened  from  its  attachment  to  the  upper  margin  of  this  cartilage  and  rib. 
The  pleura,  together  with  the  transverse  thoracic  muscle,  is  now  separated 
from  the  cartilages  and  ribs  and  retracted  to  the  left  and  a  sufficient  amount 
of  the  ribs,  together  with  the  cartilages,  is  cut  away  to  provide  the  necessary 
space  for  the  completion  of  the  operation,  which  exposes  the  heart  from  apex 
to  base.  In  case  of  injury  to  the  pleura  the  opening  is  at  once  caught  with 
clamps  and  later  ligated  or  sutured  with  catgut. 

It  is  not  always  necessary  to  make  so  complete  an  exposure  of  the  heart 
because  the  wound  may  present  itself  at  a  point  where  the  heart  is  first 
observed.  In  this  case  it  is  of  course  only  necessary  to  close  the  wound 
at  once  and  the  operation  can  be  completed  without  making  so  extensive 
a  wound.  On  the  other  hand  even  this  extensive  exposure  may  not  be  suffi- 
cient when  the  right  ventricle  has  been  injured,  in  which  case  it  is  best  to 
cut  off  the  sternum  transversely  with  bone-cutting  forceps  and  turn  it  out 
of  the  way  to  the  right.  But  it  is  only  rarely  necessary  to  make  so  complete 
an  exposure  of  the  heart. 

The  heart  is  grasped  with  two  fingers  of  the  left  hand  and  the  first 
suture  inserted  one  cm.  beyond  one  end  of  the  wound.  The  end  of  the  suture 
is  left  long  and  held  by  means  of  hemostatic  forceps  to  facilitate  the  completion 
of  a  continuous  suture.  Fine  silk  or  fine,  very  reliable  chromieized  catgut 
should  be  used  for  suturing  a  heart  wound. 

The  pericardium  and  the  pleura  are  sutured  with  catgut  at  once  without 
drainage.  The  flap  is  then  replaced  and  sutured  and  two  small  drains  inserted 
to  prevent  accumulation  of  serum  from  the  large  wound  surface. 

It  is  important  to  perform  the  entire  operation  with  the  very  greatest 
precautions  against  infection,  for  this  is  practically  certain  to  destroy  the 
life  of  the  patient  in  even  the  most  hopeful  cases  if  it  occurs. 

Transfusion  of  normal  salt  solution  is  indicated  after  the  operation  •,  and  if 
possible  transfusion  of  human  blood  by  the  method  described  elsewhere  in  this 
volume  would  undoubtedly  be  beneficial. 

EXCISION  OF  COSTAL  CARTILAGES  FOR  RELIEF  OF  EMPHYSEMA 

This  operation  has  been  strongly  recommended  because  it  reduces  the 
size  of  the  chest  and  thus  permits  the  emphysematous  portions  of  the  lung 
to  contract.  We  have  done  this  operation  for  this  particular  purpose  only  a 
few  times  and  cannot  therefore  speak  authoritatively  concerning  its  beneficial 
effects,  which,  however,  seem  reasonable.  The  same  operation  we  have  per- 
formed frequently  for  the  removal  of  diseased  cartilages.  It  is  simple  and 
Avith  reasonable  care  it  is  perfectly  safe. 

An  incision  is  made  along  one  border  of  the  sternum,  from  five  to  seven 
cm.  from  its  center,  and  extending  from  the  clavicle  to  the  lower  border  of 
the  ribs.  The  soft  tissues  are  reflected  inward  and  outward  and  each  car- 
tilage is  exposed  successively.  With  a  sharp,  heavy  cartilage  knife  the 
cartilages  are  cut  off  successively,  then  each  cut  end  is  elevated  with  a  curved 
periostome  and  from  one-half  to  three  cm.  of  the  cartilage  is  removed,  the 
shorter  excision  being  made  at  the  upper  ribs.  The  wound  is  then  closed 
and  dressed  and  a  circular  bandage  of  wide  rubber  adhesive  strips,  extending 
entirely  around  the  chest,  is  applied  the  same  as  in  the  treatment  of  gunshot 
or  stab  wounds  of  the  chest.  The  other  side  is  treated  in  the  same  manner  as 
soon  as  the  patient's  condition  warrants  a  second  operation,  which  should, 
however,  not  be  performed  too  soon. 


SURGERY  OF  THE  CHEST 


225 


Choxdrectomy  foe  Relief  of  Broxchial  Asthiia. 

(From  Dr.  E.  WyHys  Andrews,  Jourml  of  A.  If.  A.,  Sept.  26,  1914.) 
The  figure  shows  the  curved  incision  over  the  middle  of  the  costal  cartilages  of  the  second, 
third,  fourth  and  fifth  ribs.  The  wound  is  retracted  in  order  to  expose  the  entire  cartilage 
and  the  sternal  end  of  each  rib.  At  least  1  cm.  of  the  rib  with  2  cm.  of  its  periosteum  is 
removed,  together  with  the  entire  cartilage  of  the  four  ribs,  and  also  together  with  the  peri- 
chondrium, in  order  that  there  may  be  no  new  bone  or  cartilage  formed  to  fill  in  the  space,  but 
that  this  space  will  be  filled  in  with  flexible  sear  tissue  instead.  If  cartilage  and  perichondrium 
are  left  the  chest  will  soon  again  become  rigid,  and  with  this  the  patient  will  again  suffer  from 
his  former  difficulty  in  breathing.  Great  care  must  be  taken  in  removing  the  periosteum  and 
perichondrium  posteriorly  in  order  to  prevent  injury  to  the  pleura. 

FOREIGN  BODIES  LODGED  IN  THE  BRONCHI 


■  The  most  common  foreign  bodies  encountered  in  tlie  bronelii  are  small 
objects  ^vhich  children  hold  in  their  mouths  while  playing,  like  kernels  of 
corn,  peanuts,  beans,  tacks,  pins,  parts  of  playthings,  etc. 

If  these  are  of  metal  or  any  other  substance  that  will  throw  a  shadow 
when  the  chest  is  exposed  to  the  X-ray,  so  as  to  be  seen  through  a  fluoroscope, 
the  object  can  sometimes  be  grasped  with  proper  forceps  and  removed  under 
guidance  of  the  X-ray  shadow. 

Light  objects  like  kernels  of  corn,  beans,  small  buttons,  etc.,  will  usually 
be  coughed  out  of  the  tracheotomy  opening,  if  tracheotomy  is  performed 
with  a  dependent  head,  the  patient  being  placed  in  the  inverted  position  with 
the  foot  of  the  table  elevated  to  about  forty-five  degrees. 

Of  course  this  will  occur  only  if  the  object  is  not  impacted,  or  has  not 
been  fastened  by  the  occurrence  of  edema.  If  the  object  has  become  fixed 
its  location  may  usually  be  determined  by  auscultation,  as  no  air  passes  beyond 
the  location  of  the  foreign  body.  In  these  cases  a  low  tracheotomy  should 
be  made  and  a  forceps  should  be  carried  down  the  trachea  into  the  bronchus 


226  SURGERY  OF  THE  CHEST 

and  down  the  bronchus  until  it  touches  the  foreign  substance,  then  the  jaws 
of  the  instrument  should  be  opened  and  the  object  grasped  if  possible. 

At  the  present  time  it  is,  however,  scarcely  proper  for  any  one  without 
special  training  to  undertake  this  operation.  It  is  better  to  have  the  patient 
examined  with  the  bronchoscope  and  the  attempt  at  removal  made  by  an 
expert. 

So  long  as  the  object  is  in  the  trachea  its  removal,  if  this  does  not  occur 
spontaneously  upon  opening  the  trachea,  can  be  accomplished  by  any  sur- 
geon with  ordinary  skill  and  experience,  while  if  it  has  passed  lieyond  the 
bifurcation  of  the  trachea  then  one  side  of  the  lungs  is  free  and  there  is  no 
danger  of  the  patient  losing  his  life  from  asphyxiation;  at  the  same  time  the 
removal  of  the  foreign  body  becomes  thus  very  much  more  difficult,  and 
hence  there  are  two  very  good  reasons  why  the  patient  should  be  taken  to  an 
expert. 

At  times  parents  are  not  certain  as  to  whether  a  foreign  body  has  actually 
been  inspired.  In  these  instances  the  patient  frequently  does  not  reach  the 
care  of  a  surgeon  until  the  object  has  ulcerated  through  the  wall  of  the 
bronchus  and  into  the  lung,  giving  rise  to  the  formation  of  an  abscess  of 
the  lung.  In  these  cases  skiagrams  should  be  made  both  from  an  antero- 
posterior, and  from  a  lateral  view,  in  order  to  locate  the  object  as  nearly  as 
possible. 

The  treatment  indicated  is  that  advised  for  abscess  of  the  lung  from  any 
cause.  These  operations  should  be  performed  in  the  pneumatic  cabinet,  or 
with  the  help  of  the  Fell  bellows,  because  in  this  way  the  danger  from 
pneumothorax  can  be  avoided,  the  operation  performed  with  much  less  hurry 
and  the  risk  reduced  to  a  minimum. 


PART  V 

GENERAL  SURGERY  OF  THE  ABDOMEN 


There  are  a  few  conditions  connected  with  abdominal  surgery  which 
may  be  considered  in  a  general  way,  as  they  apply  to  all  cases  in  which  the 
abdominal  cavity  is  opened. 

Preparatory  treatment.  In  performing  intra-abdominal  operations  the 
matter  of  space  is  of  great  importance,  because  an  abundance  of  room  facili- 
tates the  operation  to  a  marked  degree. 

It  is  astonishing  how  much  space  may  be  gained  by  securing  an  empty 
condition  of  the  stomach  and  intestines.  If  these  are  filled  with  food,  gas 
and  residue,  the  simplest  operation  may  be  quite  difficult,  while  it  will  be 
many  times  less  troublesome  if  the  intestines  are  as  empty  as  possible.  More- 
over, the  proximity  to  the  seat  of  operation  of  decomposing  intestinal  contents 
is  not  desirable.  With  only  the  thickness  of  the  intestinal  wall  between  the 
wound  and  this  material  the  patient  is  not  nearly  so  safe  as  he  would  be  were 
the  alimentary  canal  empty. 

The  stomach.  Occasionally  the  stomach  is  found  greatly  distended  with 
gas  after  the  abdomen  has  been  opened,  and  it  may  displace  the  other  viscera, 
or  it  may  interfere  with  the  necessary  manipulations  during  the  operation 
or  after  the  operation  has  been  finished  it  may  interfere  with  the  closure 
of  the  abdominal  wound,  and  later  it  may  be  the  cause  of  much  discomfort. 
It  is  consequently  best  to  place  the  patient's  head  to  one  side  in  order  to 
prevent  inspiration  of  fluid  from  the  stomach  and  to  insert  a  stomach  tube 
and  perform  gastric  lavage  either  at  once,  as  soon  as  the  abdomen  is  opened 
if  it  interferes  with  work,  or  before  the  abdominal  wound  is  closed.  Usually 
some  bile  regurgitates  into  the  stomach  during  the  operation  and  this,  together 
with  the  mucus  the  patient  has  swallowed,  often  causes  post-operative  nausea 
which  is  eliminated  by  the  use  of  gastric  lavage  at  the  close  of  the  operation. 

In  abdominal  operations  the  infectious  material  from  a  foul  condition  of 
the  patient's  mouth  seems  especially  undesirable  and  it  is  important  to  have 
teeth  and  tongue  scrubbed  thoroughly  and  repeatedly  before  these  operations. 

Cathartics.  No  other  cathartic  has  accomplished  emptying  the  intestines 
so  thoroughly,  in  our  experience,  as  castor  oil,  given  in  the  foam  of  beer 
or  malt  extract  on  the  day  preceding  the  operation.  We  have  found  that  two 
ounces  is  the  most  satisfactory  dose.  If  given  in  this  manner  it  rarely 
nauseates  the  patient,  it  causes  very  little  or  no  pain,  and  it  is  certainly 
effective  in  almost  every  case,  leaving  the  intestines  free  from  gas  and  feces. 
It  is  well  to  give  only  sterilized  food  for  twenty-four  hours  previous  to  the 
operation,  preferably  sterilized  milk  or  broths. 

Diuretics.  After  many  intra-abdominal  operations  there  seems  to  be  an 
interference  with  the  functional  activity  of  the  kidneys,  rather  more  marked 
than  in  any  other  operations  not  performed  directly  upon  the  kidneys  or 
urinary  tracts.  It  is  consequently  wise  to  encourage  their  activity  on  the  day 
before  the  operation  by  giving  pure  water,  preferably  hot,  in  considerable 
quantities. 

227 


228  GENERAL  SURGERY  OF  THE  ABDOMEN 

The  hot  bath  which  has  been  mentioned  in  connection  with  the  prepara- 
tion of  patients  for  operation  in  general  is  especially  useful  in  these  patients, 
because  it  stimulates  the  process  of  elimination  through  the  skin  as  well  as 
through  the  kidneys.  In  case  there  should  be  a  lack  of  excretion  of  urine 
this  can  usually  be  induced  by  administering  an  enema  of  one-half  pint  of 
normal  salt  solution  every  hour  until  the  condition  is  relieved.  To  these 
enemata  from  10  to  25  grains  of  acetate  of  soda  may  be  added  until  there  is 
a  free  flow  of  urine.  The  same  result  may  be  accomplished  in  an  admirable 
manner  by  the  continuous  proctoclysis  introduced  by  Murphy  and  described 
elsewhere  herein,  normal  salt  solution  being  employed  in  this  as  in  other 
eases.  If  this  does  not  bring  satisfactory  results  1,000  cc.  of  normal  salt 
solution  may  be  injected  subcutaneously  before  and  after  the  operation. 

Abdominal  incisions.  In  making  an  incision  through  the  abdominal  wall, 
the  anatomical  layers  composing  this  wall  should  be  considered,  for  if  they 
are  not  the  closure  of  the  cavity  after  the  intra-abdominal  operation  has 
been  completed  may  not  be  satisfactory  and  may  result  in  a  weakened  point 
in  the  wall  which  may  presently  develop  into  a  hernia,  and  this  may  be  a 
many  times  more  serious  affliction  to  the  patient  than  the  condition  for  which 
the  operation  was  originally  undertaken. 

The  accompanying  plate  shows  the  arrangement  of  the  layers  of  the  abdom- 
inal muscles,  together  with  the  location  and  direction  of  the  usual  incisions 
through  the  abdominal  wall  in  the  median  line  and  on  the  right.  Of  course, 
the  same  relative  positions  would  be  suitable  on  the  left  side,  although  on 
account  of  the  location  of  the  gall  bladder  and  the  vermiform  appendix  on 
the  right  side,  many  more  abdominal  sections  are  made  through  this  than 
through  the  left  wall. 

The  incision  marked  (a)  is  suitable  for  all  operations  upon  the  intra- 
abdominal organs  located  in  the  pelvis.  In  cases  of  chronic  appendicitis  the 
vermiform  appendix  can  also  be  removed  through  this  incision. 

The  incision  marked  (b)  is  suitable  in  cases  in  which  the  vermiform 
appendix  and  the  right  ovary  and  tube  are  implicated;  (d)  indicates  the 
incision  known  as  McBurney's,  for  the  removal  of  the  appendix;  (e)  is  favor- 
able for  operations  upon  the  gall  bladder,  and  the  appendix  can  usually  also 
be  removed  through  this  incision;  (e)  offers  the  same  advantages  in  the  hypo- 
chondriac region  that  (d)  gives  in  the  iliac  region;  (f)  furnishes  an  approach 
to  the  stomach;  although  we  more  frequently  use  incision  (c)  for  this  pur- 
pose, because,  through  this  incision  we  can  more  conveniently  inspect  the 
gall  bladder,  duodenum  and  appendix. 

In  (a)  and  (f)  the  incision  is  made  through  the  linea  alba  between  the 
recti  muscles ;  (b)  and  (c)  split  the  fibers  of  the  recti  muscle,  and  (e)  and  (d) 
split  the  fibers  of  the  external  oblique,  then  the  edges  of  this  muscle  are 
retracted  and  then  the  fibers  of  the  internal  oblique  are  separated,  the  incision 
extending  at  right  angles  to  the  fibers  of  the  external  oblique.  The  incision 
is  then  extended  through  the  fibers  of  the  transversalis  fascia  and  the  peri- 
toneum. 

In  all  of  these  incisions  none  of  the  abdominal  muscles  are  cut  at  right 
angles,  which  is  of  the  greatest  importance,  for  were  they  cut  at  right  angles 
their  ends  would  be  retracted,  and  the  more  the  muscles  contract  obviously 
the  more  the  wound  shows  a  tendency  to  gape.  In  closing  a  wound  in  the 
abdominal  walls  in  which  some  of  the  muscles  have  been  cut  at  right  angles, 
it  is  often  impossible  to  secure  a  satisfactory  union  between  the  cut  ends  of 
the  muscle. 

The  conditions  are  entirely  different  if  the  muscle  fibers  have  only  been 
split  according  to  the  scheme  indicated  in  the  plate,  as  the  natural  contrac- 


GENERAL  SURGEKT  OF  THE  ABDOMEN  229 


Location  of  AbdojiixNal  Incisions. 


--   *^^^v..,j.ij.,Aij  -i-iNi-iyiONS. 

ahT„    '■''  ''''°"'    m   """"e  the  IbS™  ?m'?Wo'   'f'^JoP^^^ts  the  incisiou  tLough  tlS 
a..o...  .„,„,  ,,,,    (0    above,    (^T^ki^lfe^-l-^LnTle/te  tiali'^SilS 


230  GENERAL  SURGERY  OF  THE  ABDOMEN 

long  as  their  direction  corresponds  with  that  of  the  muscles  of  the  abdominal 
wall. 

In  order  to  make  the  position  of  these  incisions  more  clear,  they  are  shown 
in  plate  illustrating  the  surface  of  the  body  (see  Part  I),  without  indicating 
the  direction  of  the  underlying  muscles,  using  the  same  letters  as  in  the  plate 
preceding  for  the  various  incisions.     (See  Part  I.) 

Traumatism.  In  no  field  of  surgery  is  it  more  important  to  avoid  unneces- 
sary traumatism  than  in  the  abdomen.  This  can  be  accomplished  by  elimi- 
nating from  the  field  of  operation  the  portions  not  implicated  in  the  disease 
by  tamponing  them  away  with  large  pads  of  soft,  aseptic  gauze,  moistened 
with  warm,  normal  salt  solution.  These  pads  should  be  applied  carefully 
and  gently,  in  order  not  to  cause  any  traumatism,  and  left  in  place  until 
the  operation  upon  the  diseased  portion  has  been  completed. 

None  of  the  intra-abdominal  tissues  not  implicated  in  the  disease  should 
be  manipulated  during  the  operation,  in  order  to  avoid  unnecessary  shock 
and  possible  infection  and  consequent  adhesions.  Manipulation  of  inflamed 
or  congested  intra-abdominal  organs  is  especially  likely  to  give  rise  to  shock, 
and  in  these  cases  it  is  consequently  even  more  important  to  limit  the  manip- 
ulations as  much  as  possible.  So  long  as  the  peritoneal  surface  has  not  become 
abraded  the  likelihood  of  infection  is  very  greatly  reduced,  and  the  less  these 
organs  and  tissues  are  manipulated  the  less  likely  are  they  to  suffer  the 
abrasion  of  their  peritoneal  surfaces. 

Gaseous  distension.  Much  of  the  discomfort  following  abdominal  sections 
results  from  gaseous  distension  of  the  intestines.  This  can  be  reduced  to  a 
very  marked  extent  if  the  alimentary  canal  has  been  thoroughly  emptied 
before  the  operation  and  if  no  food  be  given  b}'  mouth  for  a  day  or  twio 
after  the  operation. 

The  patient  may  be  supported  very  well  by  the  administration  of  one  of 
the  numerous  predigested  foods  in  the  market  given  by  enema.  One  ounce 
of  this  is  given  in  three  ounces  of  normal  salt  solution  every  three  to  four 
hours.  Or  if  this  is  not  convenient,  a  simple  enema  of  eight  to  sixteen  ounces 
of  normal  salt  solution  given  every  three  to  four  hours  seems  to  relieve  the 
sense  of  hunger. 

Both  hunger  and  thirst  after  operation  are  relieved  by  the  use  of  con- 
tinuous normal  salt  solution  proctoclysis.  It  is  usually  best  to  give  this  for 
two  hours  continuously,  then  to  interrupt  it  for  two  hours  or  until  the  patient 
becomes  thirsty,  and  then  to  repeat.  This  also  is  an  excellent  means  for 
preventing  shock. 

The  amount  of  pain  suffered  after  an  intra-abdominal  operation  is  also 
greatly  reduced  if  no  food  be  given  by  mouth.  In  case,  however,  there 
should  still  be  a  considerable  amount  of  pain,  this  may  be  relieved  safely  by 
the  use  of  morphia  hypodermically.  This  is  not  safe  when  food  has  been 
administered,  because  the  relaxing  influence  of  morphia  upon  the  intestinal 
walls  will  have  a  tendency  to  increase  the  gaseous  distension  and  the  conse- 
quent absorption  of  products  of  decomposition.  We  wish  to  emphasize  this 
point  most  vigorously,  because  nothing  can  be  more  harmful  after  abdominal 
operations  than  the  use  of  opium  or  morphia  in  any  manner  if  some  form  of 
nourishment  is  given  by  mouth  at  the  same  time ;  while  in  cases  in  which  the 
canal  has  been  thoroughly  emptied  before  the  operation  by  the  use  of  four 
tablespoonfuls  of  castor  oil  these  remedies  may  be  employed  in  reasonable 
amounts  with  great  benefit  to  the  patient  and  entirely  without  danger. 

It  is  this  tendency  to  decomposition  in  place  of  digestion  of  food  given 
by  mouth  shortly  after  an  operation,  which  makes  it  virtually  of  no  use  to  the 
patient,  because  he  obtains  no  nourishment  from  the  food  so  taken,  while  the 
absorption  of  the  products  of  decomposition  is  a  real  injury.     There  is,  of 


GENERAL  SURGERY  OF  THE  ABDOMEN  231 

course,  the  further  advantage  in  this  feature  of  the  after-treatment  that  it 
secures  a  condition  of  rest  for  the  tissues  which  have  been  subjected  to 
traumatism,  which  in  itself  is  of  very  great  importance. 

APPENDICITIS 

In  the  consideration  of  this  subject  we  will  take  a  number  of  cases  which 
have  come  under  care  and  follow  them  through  the  various  stages  of  their 
disease,  preciselj^  as  they  progressed,  which  will  doubtless  give  a  much  more 
satisfactory  idea  of  the  plan  of  treatment  we  would  advise  than  in  describing 
the  treatment  without  reference  to  actual  clinical  cases, 

CHRONIC  RECURRENT  APPENDICITIS 

Typical  instance.  A  patient  forty-four  years  of  age,  a  maehmist  by  occupation,  gives  the 
following  history :  Ever  since  he  was  a  boy  he  has  had  occasional  attacks  of  severe  colicky 
pains  in  the  abdomen.  These  were  always  accompanied  by  nausea,  never  by  chills  or 
vomiting.  From  the  age  of  twenty  to  thirty-two  he  always  carried  some  morphine  pills, 
which  he  took  during  these  attacks,  which  never  lasted  more  than  a  few  hours.  At  this 
time  a  diagnosis  of  gall  stones  was  made.  He  always  abstained  from  taking  food  during  the 
attack  and  ate  sparingly  for  a  week  or  two  following.  At  times  the  attacks  occurred  every 
week,  then  they  would  disappear  for  a  month,  then  for  six  or  eight  months,  and  between  the 
ages  of  thirty-four  and  forty-two  he  was  entirely  free  from  actual  attacks,  but  constantly 
suffered  from  digestive  disturbances.  Fifteen  months  ago  he  had  a  recurrence  which  was 
more  severe  than  any  he  could  recall.  It  compelled  him  to  remain  in  bed  for  several  days  and 
left  a  point  in  the  right  inguinal  region  which  was  tender  upon  pressure.  Since  that  time 
he  has  had  eight  attacks,  each  one  a  little  more  severe  than  the  previous,  and  each  sufiiciently 
severe  to  prevent  him  from  going  to  his  work  for  from  three  to  ten  days.  His  last  attack 
commenced  ten  days  ago  and  he  has  been  confined  to  bed  during  this  time,  although  he  has 
not  been  severely  ill.  During  these  attacks  he  has  abstained  from  food  for  the  first  two  to 
five  days,  and  after  that  he  would  take  soups  and  milk. 

He  is  a  slightly  built  man,  muscular  development  good.  Heart,  lungs,  liver  and  kidneys 
normal;  abdomen  soft.  Upon  inquiry  he  points  to  the  right  inguinal  region  as  the  seat  of 
his  trouble.  Nothing  abnormal  can  be  found  here  except  pain  upon  deep  palpation.  This  also 
reveals  an  area  of  induration,  which  is,  however,  very  small.  His  temperature  is  below 
100°  F.,  pulse  88,  tongue  coated. 

One  peculiarity  to  which  the  patient  directs  attention  is  the  fact  that 
during  the  early  attacks  the  pains  were  spasmodic  and  came  in  waves.  The 
patient  describes  them  as  though  something  were  grasping  a  tender  portion 
of  his  intestine  and  squeezing  it  and  then  loosening  the  grasp,  only  to  tighten 
again.  During  the  past  two  years  this  condition  has  changed  and  now  the 
pain  is  more  constant  and  dull. 

We  would  explain  the  peculiarity  regarding  the  character  of  the  pain  by 
the  change  in  the  tissues  of  the  appendix.  The  muscular  coats  have  suffered 
severely  and  do  not  respond  to  irritation  as  they  did  at  first,  consequently 
the  spasmodic  character  of  the  pain  has  disappeared. 

This  is  not  at  all  an  uncommon  history.  An  individual  formerly  in 
apparently  perfect  health  and  able  to  perform  hard  labor,  suffers  for  a  period 
from  a  moderate  disturbance  of  the  digestion;  then  there  is  an  acute  attack 
of  appendicitis  from  which  the  patient  recovers  only  to  find  the  digestive 
disturbance  exaggerated.  He  returns  to  work,  but  soon  has  a  second  acute 
attack  of  appendicitis,  from  which  he  again  recovers,  only  to  repeat  his 
former  experience.  If  he  has  his  own  business,  or  is  engaged  in  the  pursuit 
of  a  profession,  he  soon  falls  behind  his  competitors  and  is  compelled  to  make 
great  sacrifices.  If  he  is  in  the  service  of  others  his  employer  will  soon 
replace  him  by  a  man  who  can  be  depended  upon. 

Prognosis.  Many  of  these  patients  have  been  encountered  suffering  from 
chronic  recurrent  appendicitis  whose  prospects  in  life  have  been  ruined  on 


232  GENERAL  SURGERY  OF  THE  ABDOMEN 

account  of  their  disease.  This,  in  itself,  is  an  ample  indication  for  radical 
treatment,  provided  that  it  will  not  result  in  complications  and  is  not  con- 
nected with  much  danger,  but  is  likely  to  result  in  a  permanent  cure. 

There  are  yet  other  valid  reasons  why  an  attempt  should  be  made  to 
relieve  the  patient  permanently.  With  each  successive  acute  attack  he  is  ex- 
posed to  a  certain  amount  of  danger  io  life.  The  fact  that  a  patient  has 
recovered  from  several  attacks  does  not  indicate  that  he  will  always  in  the 
future  be  so  fortunate.  Each  attack  undoubtedly  exposes  the  patient  to  much 
more  danger  than  tuould  an  operation  for  the  removal  of  the  appendix. 

Moreover,  the  fact  that  his  digestion  is  becoming  more  and  more  impaired 
is  certain  to  affect  his  chances  for  a  long  life.  It  is  likely  that  this  indiges- 
tion results  in  the  absorption  of  a  considerable  amount  of  products  of  decom- 
position. In  the  same  way,  septic  material  is  likely  to  be  absorbed  from  the 
lumen  of  the  obstructed  appendix. 

That  a  permanent  cure  is  to  be  looked  for,  after  the  removal  of  the 
diseased  appendix,  we  know  from  clinical  experience.  The  conditions  for 
operation  are  so  favorable  that  complications  or  unfavorable  secondary  etfects 
are  not  to  be  expected.  The  general  condition  of  the  patient  is  fair,  his 
temperature  and  pulse  are  normal,  he  is  not  suifering  from  an  acute  infec- 
tion. It  has  been  possible  to  empty  the  intestines  thoroughly  before  the  opera- 
tion, which  will  facilitate  the  operation  and  the  recovery.  It  will  not  be 
necessary  to  cause  much  traumatism,  and  any  abrasions  which  may  occur 
in  loosening  adhesions  can  readily  be  covered  with  peritoneum.  It  will  not 
be  necessary  to  drain  the  abdominal  wound  or  to  make  this  especially  large, 
hence  there  need  be  no  fear  of  the  occurrence  of  a  ventral  hernia.  Conse- 
quently we  can  reasonably  eliminate  the  fear  of  complications. 

Concerning  the  danger  of  the  operation  we  would  say  that  in  our  own 
experience  there  has  been  a  mortality  in  cases  like  the  one  outlined  of  less 
than  one  in  five  hundred,  or  one-fifth  of  one  per  cent.,  and  such  mortality 
rests  upon  accidents  which  might  occur  with  the  simplest  operation  of  any 
kind. 

For  these  reasons  we  advise  the  removal  of  the  appendix  in  cases  of  which 
the  above  is  a  type. 

Technique.  We  wish  to  direct  attention  to  the  fact  that  such  a  patient's 
abdominal  walls  are  loose  and  that  the  intestines  are  not  at  all  distended 
with  gas.  This  is  due  to  the  preparatory  treatment  consisting  in  the  admin- 
istration of  two  ounces  of  castor  oil  twenty-four  hours  before  and  a  sterilized 
liquid  diet  for  the  same  period. 

The  field  of  operation  being  prepared  in  the  usual  way  is  separated  from 
the  remaining  portion  of  the  surface  of  the  body  by  means  of  sterilized  towels, 
a  sufficient  amount  of  space  being  left  free  so  that  all  the  manipulations  neces- 
sary during  the  operation  may  be  carried  out  without  disturbing  the  towels, 
for\ve  must  not  carry  any  infectious  material  from  the  lower  surface  of  these 
towels  to  the  seat  of  operation. 

Abdominal  wound.  The  incision  is  made  parallel  with  Poupart's  ligament, 
shown  in  the  accompanying  plate,  crossing  a  point  half  way  between  the  ante- 
rior superior  spine  of  the  ilium  and  the  umbilicus,  so  that  one-third  of  the  inci- 
sion will  be  toward,  and  two-thirds  from,  the  median  line  of  the  body  as  regards 
the  above  point.  This  incision  is  carried  down  through  skin,  fascia,  fat  and 
the  external  oblique  abdominal  muscle  and  fascia,  splitting  the  fibers  of  the 
latter  with  the  blunt  end  of  the  scalpel.  The  cut  through  the  external  oblique 
may  be  made  an  inch  shorter  than  that  in  the  skin  and  it  will  still  furnish  a 
sufficient  amount  of  space.  The  edges  are  now  retracted  and  the  direction  of 
the  fibers  of  the  internal  oblique  abdominal  muscle  may  be  seen  at  right  angles 
to  the   incision.     These  fibers   are   also   separated  without   cutting,   and   we 


GENERAL  SURGERY  OF  THE  ABDOMEN  233 

expose  the  strong  transversalis  fascia,  which  is  closely  attached  to  the  peri- 
toneum. This  is  picked  up  between  two  pairs  of  dissecting  forceps,  one  in  the 
surgeon's  hand  and  one  in  the  hand  of  an  assistant.  It  requires  a  little  care 
to  avoid  picking  up  omentum  or  intestines  at  the  same  time,  but  by  lifting  the 
transversalis  fascia  with  one  pair  of  forceps,  then  picking  it  up  with  the  other, 
then  changing  the  position  of  the  first  pair  slightly,  any  intestine  or  omentum 
which  may  have  been  included  at  first  is  likely  to  be  dropped.  The  trans- 
versalis fascia  and  the  peritoneum  are  incised  carefully. 

Guides  to  the  appendix.  The  omentum  immediately  comes  into  view  crowd- 
ing itself  into  the  opening  to  protect  the  underlying  intestines.  When  this 
is  pushed  to  one  side  the  cecum  is  exposed.  This  can  be  recognized  by  the 
band  of  longitudinal  muscles  extending  along  the  anterior  surface  of  this 
portion  of  the  intestine.  Following  this  band  downwards  invariably  leads 
to  the  appendix.  By  bearing  these  facts  in  mind  it  is  possible  to  find  the 
appendix  with  the  slightest  amount  of  disturbance  of  the  abdominal  organs ; 
the  manipulations  being  confined  to  a  very  small  area.  Where  repeated  recur- 
rences, with  their  acute  inflammatory  disturbances,  have  resulted  in  extensive 
adhesions,  the  appendix  may  be  club-shaped  at  the  end  and  somewhat  bent 
upon  itself.  Its  proximal  third  may  be  loosely  adherent  to  the  lower  end  of 
the  cecum,  while  the  remaining  portion  is  strongly  adherent  to  the  anterior 
surface  of  the  iliacus  muscle. 

Adhesions.  In  separating  adhesions  it  is  always  necessary  to  exercise  the 
greatest  care,  because  occasionally  a  small  abscess  may  remain  for  a  consider- 
able period  of  time  after  an  acute  attack  of  appendicitis,  and  if  the  appendix 
is  peeled  out  carelessly  it  is  very  possible  for  the  pus  to  come  in  contact 
with  other  parts  of  the  peritoneal  cavity  and  a  peritonitis  may  then  occur. 
Again,  a  perforation  into  the  cecum,  or  the  ileum,  may  have  occurred  during 
an  acute  attack  and  the  communication  between  the  lumen  of  the  appendix 
and  the  intestine  may  not  have  healed  entirely,  and  upon  removing  the 
appendix  a  small  intestinal  fistula  may  be  left,  which  again  may  become  the 
cause  of  peritonitis.  In  case  there  is  an  attachment  to  the  cecum  or  ileum 
the  surface  from  which  the  appendix  has  been  removed  should  be  covered 
at  once  by  means  of  a  few  Lembert  sutures. 

Again  it  may  happen  that  the  lumen  of  the  appendix  at  its  cecal  end  is 
occluded  and  that  the  sac  which  is  thus  formed  is  filled  with  pus.  Unless 
great  care  is  exercised  in  dissecting  the  appendix  out  of  its  adhesions  it  is 
liable  to  perforate  during  the  operation  and  cause  an  infection. 

Prevention  of  peritoneal  adhesions.  Recently  various  methods  have  been 
recommended  for  the  prevention  of  post-operative  peritoneal  adhesions,  espe- 
cially in  the  presence  of  drainage  tubes. 

Our  experience  has  not  been  sufficient  with  any  of  these  to  warrant  definite 
statements.  We  have  placed  cigarette  drains  composed  of  gauze  surrounded 
by  rubber  tissue  .in  many  cases  with  apparent  success.  We  have  also  filled 
the  peritoneal  cavity  with  5  per  cent,  citrate  of  soda  in  normal  salt  solution, 
also  sterile  liquid  vaseline.  We  have  not  made  use  of  a  solution  of  herudin 
which  has  been  mentioned  very  favorably  by  many  experimenters,  neither 
have  we  made  use  of  adrenalin  solutions.  It  has  seemed  to  us  that  absence 
of  even  the  slightest  unnecessary  traumatism  is  of  the  very  greatest  importance 
and  far  outweighs  all  other  possible  elements. 

Removing  the  appendix.  The  removal  of  the  appendix  may  now  be  accom- 
plished as  illustrated.  (1)  A  pair  of  forceps  is  applied  to  the  mesentery 
of  the  appendix.  (2)  The  mesentery  is  severed  between  the  appendix  and 
the  forceps.  (3)  Two  pairs  of  forceps  are  applied  to  the  appendix  at  the 
point  of  its  origin  from  the  cecum.  (4)  The  mesentery  of  the  appendix  is 
ligated   and  the  forceps  holding  this  structure   is  removed.      (5)   A  purse- 


234  GENERAL  SURGERY  OF  THE  ABDOMEN 

string  stitch  is  applied  from  one-eighth  to  one-fourth  of  an  inch  from  the 
base  of  the  appendix.  These  steps  are  shown  in  the  accompanying  plate, 
although  in  practice  the  forceps  on  the  mesentery  is  removed  before  the  purse- 
string  suture  is  applied.  The  presence  of  the  forceps  on  the  appendix  facili- 
tates the  application  of  the  purse-string  suture  and  at  the  same  time  acts 
after  the  fashion  of  an  angiotribe,  crushing  the  tissues  of  the  appendix  into 
a  thin  laj'er,  as  shown. 

The  appendix  is  now  cut  awa}^  even  with  the  forceps,  care  being  taken 
to  prevent  leakage  by  apphing  another  pair  of  forceps  half  an  inch  nearer 
the  distal  end  of  the  appendix  before  cutting  it  away.  The  crushed  stump 
of  the  appendix  is  then  grasped  by  a  pair  of  smooth  dissecting  forceps,  or 
with  a  probe  containing  a  fine,  short  needle  at  its  end,  and  inverted  into  the 
cecum  while  an  assistant  draws  the  circular  stitch  tightly,  thus  closing  the 
defect.  The  defects  caused  by  the  removal  of  the  appendix  are  then  covered 
with  peritoneum  by  means  of  a  few  fine  silk  sutures  and  then  a  few  more 
sutures  are  applied  to  cover  the  space  occupied  by  the  purse-string  suture. 
It  is  not  always  that  these  last  stitches  are  essential,  but  a  little  too  much  care 
is  excusable,  so  long  as  it  is  harmless. 

Ligatures  and  stitches.  In  some  cases  the  stump  is  very  vascular,  which 
may  make  it  desirable  to  apply  a  fine,  catgut  ligature  to  its  crushed  end,  but 
this  is  not  usually  necessary.  In  applying  the  purse-string  suture  the  needle 
should  take  a  sufficiently  deep  bite  to  include  all  the  layers  down  to  the  mucosa, 
the  connective  tissue  next  to  the  mucosa  being  the  most  important  layer. 

It  does  not  matter  whether  fine  silk  or  fine  catgut  be  employed  for  these 
sutures,  but  in  our  own  practice  fine  silk  is  used  for  all  sutures  applied  to 
the  intestinal  walls.  As  a  matter  of  convenience  we  use  an  ordinary  straight 
sewing  needle  or  a  fine  curved  needle  with  the  fine  silk  double,  in  order  to 
prevent  twisting  and  unthreading,  because  the  sutures  may  be  applied  more 
rapidly  in  this  way  than  b}^  sewing  with  a  single  thread. 

The  entire  field  of  operation  is  carefully  inspected  once  more  and  if  any 
abrasion  is  found  this  is  covered  with  a  few  Lembert  sutures,  then  the 
intestine  is  dropped  into  the  peritoneal  cavity  and  the  abdominal  wound 
closed  in  the  following  manner: 

Closure  of  the  abdominal  wound.  The  peritoneum  and  transversalis  fascia 
are  first  caught  with  forceps  and  then  united  by  means  of  a  continuous  catgut 
suture.  In  this  part  of  the  abdominal  wall  the  transversalis  fascia  is  strong 
and  is  sometimes  likely  to  retract  so  that  it  is  quite  liable  to  be  overlooked. 
As  this  error  would  weaken  the  abdominal  wall  quite  a  little  at  this  point,  it  is 
well  to  bring  both  the  peritoneum  and  the  transversalis  fascia  together  care- 
fully with  this  suture. 

The  edges  of  the  internal  oblique  muscle  fall  in  apposition  spontaneously 
as  soon  as  the  peritoneum  and  transversalis  fascia  have  been  sutured,  and 
without  any  further  interference  there  would  probably  be  a  perfect  union 
in  the  layer.  To  insure  this  still  more  fully,  however,  we  apply  one  or  two, 
or  even  three,  interrupted  catgut  sutures  through  this  muscle.  It  is  impor- 
tant to  tie  these  sutures  very  loosely,  as  pressure-necrosis  in  this  position 
would  result  in  retraction  of  the  muscle  and  this  would,  of  course,  produce  a 
marked  weakening  of  the  abdominal  wall  at  this  point. 

The  edges  of  the  wound  in  the  external  oblique  muscle  and  fascia  have 
been  held  apart  by  means  of  retractors,  in  order  to  expose  the  internal 
oblique  thoroughlA'.  These  retractors  are  now  removed  and  immediately  the 
edges  of  the  muscle  and  fascia  approach  each  other.  With  this  natural 
tendencj^  of  the  edges  in  wounds  of  these  two  muscles  to  approximate  them- 
selves without  the  use  of  sutures,  there  need  be  no  fear  of  the  formation  of 


GENERAL  SURGERY  OF  THE  ABDOMEN  235 

a  post-operative  hernia,  because  these  two  strong  layers  extend  at  right 
angles  to  each  other. 

The  edges  of  the  wound  in  the  external  oblique  muscle  are  now  united, 
as  illustrated,  care  being  again  used  not  to  draw  the  stitches  too  tightly  for 
the  reason  given  above. 

In  the  three  plates  just  referred  to  (see  following  pages),  deep  silkworm  gut 
sutures  are  figured  as  placed  in  position,  but  not  tied.  These  may  be  used  if 
desired  and  tied  after  the  buried  sutures  have  been  applied,  but  they  are  not 
necessary  to  secure  a  perfect  union  (and  unless  there  is  an  unusual  amount  of 
tension  in  any  case  we  do  not  use  them,  depending  entirely  upon  the  catgut 
sutures).  In  the  next  plate  these  stitches  are  figured  as  having  been  tied  and 
the  skin  is  being  united  by  means  of  a  continuous,  buttonhole  stitch  of  horse- 
hair. The  latter  is  again  used  double,  in  order  to  prevent  unthreading  of  the 
needle.  It  does  not  matter  what  form  of  stitch,  or  what  material  is  used, 
for  the  coaptation  of  the  skin  so  long  as  the  material  is  aseptic.  A  dressing 
of  aseptic  gauze  is  applied  to  the  surface  and  held  in  place  with  broad  rubber 
adhesive  plaster  strips,  in  order  to  support  the  abdominal  wall.  This  is 
covered  with  a  sheet  of  sterile  absorbent  cotton  which  is  held  in  place  with 
an  abdominal  binder. 

Pathological  appearances  of  the  appendix.  The  specimen  is  a  little  over 
four  inches  in  length,  which  is  considerably  less  than  it  was  before  its  removal, 
because  the  longitudinal  muscle  fibers  have  been  contracted,  and  this  has 
resulted  in  a  marked  shortening  of  the  organ.  Its  mesentery  is  quite  thick 
and  extends  a  little  beyond  the  end  of  the  appendix.  This  condition  has 
probably  served  to  protect  the  organ  against  more  extensive  destruction, 
because  in  this  way  a  fair  blood  supply  has  been  insured  to  the  entire  part, 
although  locally  it  may  have  suffered  severely.  About  one-half  inch  from 
its  cecal  end  there  is  quite  a  marked  narrowing  in  the  lumen,  and  by  inspec- 
tion and  palpation  one  may  determine  the  presence  of  a  considerable  amount 
of  cicatricial  tissue  at  this  point.  The  narrowing  is  shown  in  the  plate. 
Beyond  this  constriction  we  feel  several  hard  masses  in  the  lumen  of  the 
appendix  which  are  undoubtedly  due  to  fecal  concretions.  Upon  laying  open 
the  part,  these  concretions  show,  by  the  irregular  forms  into  which  they 
have  been  molded  by  the  irregularities  in  the  lumen  of  the  appendix,  that 
they  must  have  been  in  this  portion  for  a  considerable  period  of  time.  The 
mucous  lining  of  the  appendix  shows  a  number  of  cicatrices  resulting  from 
ulcers  which  have  healed,  and  at  the  narrowest  point,  near  the  cecum,  the 
entire  wall  seems  to  be  composed  of  cicatricial  tissue,  showing  that  there 
must  have  been  at  some  time  a  complete  destruction  of  a  portion  of  the  wall 
of  the  appendix.  The  lumen  at  this  point  is  so  small  that  a  slight  edema 
would  suffice  to  close  it  entirely,  and  with  this  closure  would  disappear  the 
drainage  of  the  cavity  of  the  appendix.  The  septic  material  present  in  this 
lumen  would,  of  course,  increase  very  rapidly  so  soon  as  drainage  had  com- 
pletely disappeared,  and  this  would  result  in  a  recurrent  attack. 

The  digestive  disturbances  with  which  such  a  patient  is  afflicted  can  be 
explained,  first,  from  the  interference  with  the  fecal  circulation  because  of 
the  extensive  adhesions  drawing  the  intestines  out  of  place ;  second,  from  the 
fact  that  the  ileo-cecal  valve  prevents  the  passage  of  gas  and  feces  when 
there  is  an  irritation  or  inflammation  in  the  appendix,  and  consequently  the 
constant  inflammation  in  this  organ,  for  perhaps  a  number  of  years,  results 
in  an  almost  constant  obstruction  to  the  passage  of  gas  and  feces  from  the 
ileum  into  the  cecum,  and  this,  of  course,  causes  digestive  disturbances. 


286 


GENERAL  SURGERY  OF  THE  ABDOMEN 


Excision    of    AppExXdix. 

Eepresents  the  excision 
of  the  vermiform  appen- 
dix, a  clamp  being  placed 
at  the  base  of  the  appen- 
dix, a  second  one  upon 
the  mesenteriolum ;  a  lig- 
ature is  in  position  to  tie 
the  mesenteriolum ;  the 
scissors  are  in  position  to 
cut  the  mesentery  between 
the  appendix  and  the 
clamp  upon  the  former; 
a  purse-string  suture  has 
been  placed  about  the 
base  of  the  appendix  upon 
the  end  of  the  cecum. 


Cecum    with    Appendix 
Eemoved. 

Represents  the  end  of 
the  cecum  after  the  ap- 
pendix has  been  cut  away, 
the  remaining  portion 
showing  the  effects  of  the 
pressure  from  the  clamp. 
The  figure  should  show 
the  mesenteriolum  ligated 
and  cut,  instead  of  show- 
ing a  slit  in  the  peritc^- 
neum,  covering  the  cecal 
end  of  the  ileum. 


>  Excision  of  Appendix. 

Represents  the  appendix  buried  by  a  second  row  of  sutures.  The  longitudinal  muscular 
band  is  sliown  to  extend  down  to  the  origin  of  the  appendix  in  each  of  these  drawings  of 
the  cecum. 


GENERAL  SURGERY  OF  THE  ABDOMEN  237 

Atypical  conditions.  In  many  of  these  instances  of  chronic  recurrent 
appendicitis  it  is  much  more  difficult  to  remove  the  appendix  than  has  just 
been  stated,  because  it  may  be  located  in  some  position  from  which  it  can  be 
dissected  only  with  great  difficulty.  A  not  uncommon  location  is  on  the 
posterior  surface  of  the  cecum.  Plere  it  is  frequently  completely  covered  with 
adhesions. 

In  these  cases  the  end  is  usually  club-shaped  and  filled  with  fecal  material, 
pus  or  mucus.  Frequently  there  has  been  a  perforation  between  the  appendix 
and  the  cecum,  and  occasionally  there  is  a  fistula  which  has  persisted  for  a 
long  time.  The  cecum,  together  with  the  appendix,  may  be  united  by  adhesions 
to  the  anterior  surface  of  the  iliacus  muscle  or  to  the  omentum,  or  to  both. 
The  appendix  may  also  be  displaced  very  greatly.  It  has  been  found  attached 
to  the  left  of  the  median  line,  even  to  the  border  of  the  spleen.  We  have 
found  it  attached  to  each  of  the  pelvic  organs,  uterus,  bladder,  ovaries,  tubes, 
sigmoid  flexture  and  rectum ;  also  to  the  small  intestines,  to  the  anterior 
abdominal  wall  and  to  the  gall  bladder.  Indeed,  with  a  long,  free  cecum  there 
is  no  reason  why  the  appendix  should  not  be  found  attached  to  any  point 
within  the  abdominal  cavity. 

Many  times  we  have  seen  the  appendix  twisted  upon  itself  like  a  snail 
and  held  in  this  position  by  adhesions,  making  the  evacuation  of  its  cavity 
practically  impossible.  In  many  cases  there  are  several  strong  adhesions  at 
various  points  in  the  course  of  the  appendix,  making  short  bends,  which 
have  a  tendency  to  obstruct  its  lumen.  The  distal  end  of  the  appendix  may 
project  beyond  the  last  one  of  these  adhesions  and  form  a  free,  sac-like  pro- 
jection. 

It  frequently  happens  that  the  strong  adhesions  are  located  opposite  a 
point  at  which  there  was  a  perforation  in  the  appendix  during  an  acute  attack. 
This  will,  of  course,  still  further  obstruct  the  lumen  at  this  point. 

Occasionally  an  appendix  is  found  in  which  the  greater  portion  of  the 
structure  has  been  destroyed  by  gangrene  and  has  been  absorbed,  leaving 
only  a  small,  string-like  structure  along  the  edge  of  the  mesentery  of  the 
appendix.  Again,  the  cecal  end  may  have  been  destroyed  in  the  same  way, 
leaving  the  distal  end  without  communication  with  the  cecum.  This  condi- 
tion is  likely  to  be  troublesome  because  it  leaves  a  sac,  lined  with  mucous 
membrane  containing  septic  material,  without  drainage  into  the  cecum. 

In  still  other  cases  the  appendix  has  become  so  intimately  united  with 
the  posterior  surface  of  the  cecum  that  it  can  be  discovered  only  after  the 
most  careful  search  has  been  made,  because  both  the  appendix  and  the 
underlying  cecum  are  covered  with  a  broad  sheet  of  connective  tissue,  which 
has  almost  perfectly  the  appearance  of  peritoneum.  In  these  instances  it 
frequently  happens  that  the  proximal  end  of  the  appendix  is  entirely  occluded 
and  that  the  distal  end  contains  septic  material  which  gives  rise  to  the  recur- 
rent attacks  of  appendicitis,  which  subside  only  when  the  abscess  formed  has 
perforated  into  the  cecum. 

The  longitudinal  band  of  muscle  fibers  serves  better  than  any  other  guide 
to  the  discovery  of  the  location  of  the  appendix  in  these  examples. 

The  operator  may  easily  be  deceived  in  searching  for  the  appendix,  in 
the  interval  in  recurrent  appendicitis,  by  the  presence  of  a  small  mass  of 
fat  at  the  lower  end  of  the  cecum.  This  may  lead  him  to  suppose  that  the 
appendix  has  been  entirely  destroyed  on  account  of  gangrene  and  that  all 
that  is  left  is  simply  the  fat  mesentery  of  the  appendix.  Careful  inspection 
will  usually  show  that  this  mass  of  fat  consists  of  a  small  portion  of  omentum 
which  has  surrounded  the  appendix  and  has  become  thoroughly  adherent 
to  the  latter  or  to  its  remnant  after  the  portion  destroyed  by  the  disease 
has  been  absorbed.     So  long  as  the  operator  follows  the  longitudinal  muscle 


238  GENERAL  SURGERY  OF  THE  ABDOMEN 

band  upon  the  anterior  surface  of  the  cecum,  and  at  the  same  time  is  as 
careful  as  possible  not  to  injure  the  walls  of  the  loops  of  intestine  which 
may  be  adherent,  his  search  for  the  appendix  may  be  conducted  with  relative 
safety. 

Important  conclusions.  The  important  points  to  be  borne  in  mind  in 
connection  with  recurrent  appendicitis  are:  1,  The  patient's  opportunities 
for  professional  or  business  prosperity  are  greatly  limited  by  the  frequent 
interruptions  due  to  the  disease.  2,  He  is  deprived  of  many  of  the  ordi- 
nary pleasures  of  life.  3,  He  is  constantly  in  danger  of  suffering  from  a 
serious  attack.  4,  His  digestion  is  impaired  and  his  nutrition  is  correspond- 
ingly reduced.  5,  He  is  forced  to  absorb  septic  material  during  a  consider- 
able portion  of  the  time.  6,  During  any  attack  any  of  the  various  complica- 
tions residting  from  acute  appendicitis  may  occur.  7,  So  large  a  proportion 
of  these  cases  suffer  from  gall  stones  that  this  condition  may  be  reasonably 
looked  upon  as  being  secondarj^  to  the  appendicitis  in  some  instances. 

All  of  these  conditions  can  be  eliminated  by  an  operation  which  in  itself 
is  not  accompanied  with  as  much  danger  as  there  is  in  any  one  attack  of 
recurrent  appendicitis,  and  which  will  confine  the  patient  for  a  very  short 
time,  provided,  always,  that  the  operation  is  performed  by  a  safe  surgeon 
and  after  the  acute  attack  has  subsided  completely. 

ACUTE  PERFORATIVE  APPENDICITIS 

Typical  history.  The  patient  is  fourteen  years  of  age,  a  school-girl  slightly  built,  and 
not  well  developed  for  her  age.  She  has  never  heen  strong  since  infancy,  which  she  attributes 
to  the  fact  that  she  suffered  from  measles  and  scarlet  fever  while  very  young.  Her  nutri- 
tion has  always  been  imperfect  and  her  appetite  unnatural,  being  either  ravenous  or  entirely 
absent.  Her  bowels  have  been  constipated  and  abdomen  bloated.  She  has  menstruated  since 
one  year  ago  at  irregular  times  and  has  suffered  severely  from  pain  in  the  region  of  the 
right  ovary  during  each  period.  The  pain  has  been  spasmodic  and  so  severe  that  the  use  of 
anodynes  seemed  necessary  for  her  relief.  She  never  suffered  from  severe  pain  at  any  other 
time,  although  she  occasionally  had  slight  attacks  of  colic  in  the  epigastric  region  whenever 
she  was  especially  careless  about  eating.  Three  days  ago,  immediately  after  an  unusually 
large  dinner  the  patient  suddenly  experienced  severe  pain  over  the  entire  abdomen,  but  which 
was  more  intense  in  the  vicinity  of  the  umbilicus. 

The  patient  was  put  to  bed  and  hot  cloths  were  applied  to  the  abdomen,  affording  only 
slight  relief;  she  was  then  given  a  large  dose  of  salts,  followed  by  a  cup  of  hot  water.  Being 
slightly  nauseated  before,  this  condition  increased  very  rapidly,  resulting  in  severe  vomiting, 
which  has  persisted  at  intervals  ever  since.  Two  days  ago  she  received  several  enemata,  one 
of  which  was  followed  by  the  expulsion  of  gas  and  some  feces.  The  patient  received  soups 
and  milk  by  mouth,  but  could  not  retain  the  nourishment  more  than  a  few  hours  at  a  time, 
when  she  would  vomit  whatever  had  been  taken.  All  remedies  administered  to  relieve  the 
nausea  and  vomiting  were  of  no  avail.  Several  further  enemata  were  given  without  effecting 
the  expulsion  of  gas  or  feces.  The  abdomen  became  more  and  more  tympanitic  and  the  pain 
became  so  severe  that  morphia  had  to  be  used  hypodermically.  The  pulse  increased  to  130 
beats  per  minute  and  the  temperature  to  102.5°.  The  pain  has  become  localized  in  the  right 
inguinal  region. 

The  general  appearance  of  the  patient  is  extremely  unsatisfactory.  She  gives  the  impres- 
sion of  one  who  is  almost  hopelessly  ill.  She  has  an  anxious,  restless  expression.  Her  bre-athing 
is  entirely  costal,  rapid  and  short.  Her  abdomen  is  severely  distended  and  more  prominent 
in  the  right  inguinal  region  than  in  the  left.  The  abdominal  muscles  are  exceedingly  tense, 
especially  on  the  right  side.  The  patient  shrinks  if  she  notices  any  one  approaching  the  bed, 
although  she  seems  too  ill  to  show  interest  in  anything  else. 

TJpon  percussion  we  find  a  little  difference  in  resonance  in  the  two  inguinal  regions,  but 
neither  side  gives  a  dull  or  a  flat  sound.  The  patient  complains  of  pain  from  percussion  on  the 
right   side. 

Upon  examination  through  the  rectum  we  find  this  organ  distended  mth  gas  above  the 
internal  sphincter,  which  is  supposed  to  indicate  the  presence  of  diffuse  peritonitis.  On  the 
right  side  the  finger  perceives  a  fullness,  but  no  fluctuation.  Her  thighs  are  drawn  up  to 
relieve  the  tension  of  the  abdominal  muscles.  The  nurse  has  nlaeed  a  pillow  under  her  knees 
to  make  this  position  more  comfortable.  The  patient's  temperature  is  nearly  103°  F.  and  the 
pulse  130  beats  per  minute  and  very  feeble.  Her  tongue  is  thickly  coated  and  the  edges  are 
red  in  small  spots.     She  is  intensely  thirsty,  but  does  not  retain  the  liquid  given  to  her. 


GENERAL  SURGERY  OF  THE  ABDOMEN 


239 


The  patient  is  evidently  suffering  from  acute  perforative  appendicitis  with  beginning 
diffuse  peritonitis.  This  may  be  due  to  the  perforation  of  an  ulcer  which  has  existed  for  a 
considerable  period  of  time,  or  to  gangrene  of  the  appendix,  from  thrombosis  of  some  of 
its  vessels,  or  to  the  perforation  of  an  appendix  distended  with  pus  with  its  cecal  end  occluded 
by  cicatricial  tissue.  The  patient  is  extremely  ill,  and  it  is  plain  that  unless  the  method  of 
treatment  employed  during  the  past  three  days  is  radically  changed  she  cannot  survive  long. 

Considerations  of  treatment.  So  far  the  patient  has  received  the  treatment 
prescribed  by  many  of  the  leading  text-books  on  internal  medicine.  She  has 
been  limited  to  liquid  diet,  has  received  saline  cathartics  and  enemata,  has 


Closure  of  Wound  of  McBurney  's  Incision  for  the  Eemoval  of  the  Vermiform  Appendix. 

The  incision  is  parallel  with  Poupart's  ligament.  Its  center  is  in  the  line  drawn  from  the 
umbilicus  to  the  anterior  superior  spine  of  the  ilium  and  half  way  between  these  two  points. 

The  aponeurosis  of  the  external  oblique  abdominal  muscle  is  shown  split  parallel  with 
its  fibres  in  the  direction  of  the  skin  wound. 

The  internal  oblique  abdominal  muscle  is  split  in  the  direction  of  its  fibres  at  right  angles 
with  the  direction  of  the  wound  in  the  skin.  Sutures  have  been  applied  to  the  transversalis 
fascia  and  peritoneum  and  deep  silkworm  gut  sutures  have  been  inserted  through  all  layers 
down  to,  but  not  through,  the  peritoneum.  A  few  catgut  sutures  are  to  be  applied  to  bring 
the  edges  of  the  internal  oblique  abdominal  muscle  together,  and  a  continuous  catgut 
suture  for  the  purpose  of  uniting  the  aponeurosis  of  the  external  oblique  abdominal  muscle. 

The  skin  is  sutured  with  horsehair  or  silk  and  then  the  silkwonn  gut  sutures  are  tied  over 
all.     It  is,  however,  quite  safe  to  omit  the  silkworm  gut  sutures  altogether. 


had  hot  applications  to  the  abdomen,  and  when  the  pain  has  been  unbearable 
opium  was  employed  onlj^  in  sufficient  doses  to  overcome  the  severe  distress. 
There  can  be  no  doubt  from  the  progress  of  the  disease  that  such  treatment 
was  extremely  unfortunate  in  this  case.  We  believe  that  this  form  of  treat- 
ment should  be  condemned  in  every  case  of  acute  appendicitis,  because  it  con- 
tains nothing  which  can  be  useful  for  the  relief  of  the  pathological  conditions 


2^0  GENERAL  SURGERY  OF  THE  ABDOMEN 

present,  while  it  includes  many  features  which  are  extremely  harmful,  as  we 
shall  see  presently. 

The  giving  of  cathartics  of  any  kind  during  acute  gangrenous  or  perforative 
appendicitis  at  any  time  during  the  attack  has  undoubtedly  destroyed  more 
lives  than  surgery  has  saved  in  this  disease. 

The  question  arises.  What  can  we  do  for  this  patient  that  will  be  of  great- 
est benefit  to  her  and  may  possibly  rescue  her  from  the  present  apparently 
hopeless  condition  ? 

Many  authors  advise  an  immediate  operation  in  all  cases  of  acute  appen- 
dicitis without  regard  to  the  condition  of  the  patient  or  the  stage  of  the  attack, 
unless  the  patient  is  moribund  on  the  one  hand  or  improving  rapidly  under 
the  treatment  which  is  being  employed  at  the  time  the  surgeon  is  called. 

Although  this  patient  is  very  ill,  she  is  not  moribund,  consequently  this 
case  Avould  come  under  the  class  in  which  an  immediate  operation  is  advised 
by  these  authorities.  In  our  experience,  and  in  that  of  all  surgeons  whose 
work  we  have  had  an  opportunity  to  observe,  patients  with  the  conditions 
of  the  case  described  have  almost  invariably  died  within  twenty-four  or 
forty-eight  hours  after  the  operation.  They  therefore  belong  to  a  class  in 
which  operative  treatment  has  an  especially  high  mortality.  In  fact,  by  far 
the  greater  portion  of  all  fatal  cases  following  appendicitis  operations  belong 
to  this  class.  These  cases  have  been  said  to  be  too  late  for  an  early,  and  too 
early  for  a  late  operation. 

Our  experience  has  been  quite  different  with  a  form  of  treatment  which 
we  will  proceed  to  set  forth.  Of  course,  no  form  of  treatment  can  save  every 
case  of  perforative  appendicitis,  especially  if  the  patient  has  received  cathartics 
and  food  by  mouth  before  he  comes  under  care,  but  in  cases  like  the  one  de- 
picted we  would  estimate  the  proportion  of  recoveries  at  about  ninety  per  cent, 
if  the  method  which  we  recommend  be  employed. 

Taking  all  cases  of  gangrenous  and  perforative  appendicitis  together,  as  a 
class,  as  they  come  under  our  care  at  the  hospital,  those  that  are  like  the  case 
named  and  those  that  are  not  so  severe  but  still  having  gangrene  or  perfora- 
tion present,  and  those  that  are  still  worse,  our  mortality  is  now  a  little  less 
than  two  per  cent. 

Had  it  been  possible  from  the  beginning  to  confine  the  septic  material  to 
the  vicinity  of  the  appendix,  the  patient's  condition  Avould  never  have  become 
as  serious  as  at  present,  because  her  serious  condition  is  undoubtedly  due  to 
the  fact  that  the  septic  material  has  been  distributed  over  a  considerable  por- 
tion of  the  peritoneum,  as  a  direct  result  of  peristaltic  motion  of  the  intestines 
caused  by  the  giving  of  food  and  cathartics  by  mouth. 

Anatomical  surroundings  of  the  appendix.  In  order  to  comprehend  fully 
the  treatment  we  advise  in  this  class  of  cases,  it  will  be  necessary  to  direct 
attention  to  the  anatomical  location  of  the  appendix. 

The  appendix  is  virtually  surrounded  on  all  sides,  excepting  in  the  direction 
of  the  median  line,  by  relatively  fixed  tissues.  Above  we  find  the  lower  end 
of  the  cecum  and  the  cecal  end  of  the  ileum;  to  the  right  and  in  front  is  the 
parietal  peritoneum;  behind  the  peritoneum  covering  the  iliacus  muscle;  and 
toward  the  median  line  it  is  surrounded  by  loops  of  small  intestines.  More- 
over, the  omentum  extends  far  beyond  its  lower  end.  (In  small  children  the 
omentum  is  so  slight  in  many  cases  that  it  cannot  be  considered  of  great  value 
in  protecting  a  gangrenous  appendix.) 

It  is  true  that  the  appendix  may  be  displaced  downward,  but  in  this  event 
it  will  again  be  surrounded  by  fixed  tissues  which  seem  especially  adapted  to 
dispose  of  septic  material.  Again,  there  may  be  an  enteroptosis  affecting  the 
cecum,  and  always  with  this  a  marked  lowering  of  the  transverse  colon  and 
stomach,  and  with  these,  the  omentum. 


The  twelve  colored  illustrations  shown  here  give  practically  all  of  the  more  usual  forms 
of  appendicitis  which  one  is  likely  to  encounter. 

Fig.  1  shows  an  appendix  with  a  side,  funnel-shaped,  cecal  end,  the  entire  appendix  taper- 
ing uniformly  from  the  point  of  its  attachment  to  the  cecum.  Appendices  of  this  form,  in  our 
experience,  are  likely  to  give  rise  to  digestive  disturbances.  Apparently  fecal  material  is 
forced  into  these  appendices  and  is  forced  out  again  without  giving  rise  to  serious  symptoms, 
because  an  obstruction  is  quite  unlikely  to  occur.  The  irritation  of  this  process,  however, 
is  liable  to  incapacitate  the  patient  to  a  marked  extent.  The  removal  of  the  organ  is  usually 
followed  by  prompt  relief. 

Fig.  2.  This  appendix  is  narrow  at  the  cecal  end  and  club-shaped  at  its  distal  end.  It 
may  give  rise  to  mild  septic  symptoms  which  are  usually  followed  sooner  or  later  by  gangrene 
of  the  mucous  membrane  or  of  a  greater  or  smaller  portion  of  the  entire  appendix.  The 
condition  is  very  much  more  serious  than  that  illustrated  in  Fig.  1. 

Fig.  .3.  In  this  case  the  cecal  end  of  the  appendix  is  almost  compdetely  covered.  The 
distal  end,  besides  being  club-shaped,  is  curved  upon  itself  like  a  shepherd 's  crook.  Patients 
suffering  from  appendicitis  in  this  form,  although  they  may  recover  spontaneously,  are  never 
entirely  well  until  the  appendix  has  been  removed,  because  its  distal  end  constantly  contains 
septic  material. 

Fig.  4.  This  appendix  has  two  constricted  portions,  one  near  its  cecal  end,  and  one  a  little 
beyond  its  middle,  showing  that  at  some  time  the  mucous  membrane  must  have  been  gangrenous 
and  sloughed  away,  leaving  two  portions  of  the  lumen  containing  mucous  membrane  or  septic 
material.     A  patient  with  such  an  appendix  will  also  not  be  well  until  it  is  removed. 

Fig.  5.  This  appendix  is  curled  upon  itself  like  a  snail.  There  is  a  sheet  of  connective 
tissue  tying  it  down.  The  cecal  end  is  narrow.  Patients  with  such  an  appendix  are  never 
free  from  discomfort. 

Fig.  6  shows  an  appendix  with  a  perforation  of  its  distal  end.  This  type  corresponds 
to  that  shown  in  Fig.  2,  with  the  addition  of  the  gangrene  which  has  evidently  supiervened. 

Fig.  7  shows  a  fairly  common  type  of  chronic  appendicitis  obliterans,  in  which  the  cecal 
end  is  funnel-shaped,  while  the  distal  two-thirds  of  the  very  long  appendix  is  almost  entirely 
cicatricial  in  character. 

Fig.  8  shows  the  end  of  the  cecum  with  a  fragment  of  the  ileum  and  an  almost  com- 
pletely destroyed  appendix  bound  strongly  to  the  lower  end  of  the  cecum  by  means  of  con- 
nective tissue.  In  case  there  is  still  a  slight  amount  of  mucous  membrane  left  in  an  appendix 
of  this  type,  the  patient  may  continue  to  be  in  a  slightly  septic  condition  for  months  or  years, 
which  will  disappear  immediately  upon  the  removal  of  this  structure. 

Fig.  9  represents  an  enormously  distended,  short  appendix  whose  walls  are  many  times 
the  normal  thickness.  The  mucous  membrane  in  these  cases  is  covered  to  a  greater  or  lesser 
extent  with  granulation  tissue.  In  case  the  cecal  end  is  occluded  because  of  the  thickness  of 
the  wall  and  the  presence  of  granulation  tissue,  the  distal  end  may  be  distended  with  mucous 
or  pus,  and  it  frequently  contains  fecal  concretions.  Patients  suffering  from  this  condition 
usually  have  frequently  recurring  attacks  which  not  infrequently  end  in  perforation. 

Fig.  10  represents  a  short,  thick- walled  appendix  with  a  fecal  concretion  lodged  in  an 
ulcerated  area  with  beginning  gangrene  of  the  surrounding  mucous  membrane.  This  appen- 
dix is  widely  open  at  its  cecal  end,  making  continuous  drainage  into  the  cecum  possible. 

Fig.  11  represents  an  appendix  with  similarly  thickened  wall.  An  ulcerated  area  is  pres- 
ent near  its  distal  end,  containing  mucous  and  pus,  but  no  concretion.  The  appendix  is 
narrowed  at  one-third  its  distance  from  the  cecal  to  the  distal  end,  to  such  an  extent  that  the 
lumen  of  the  distal  end  cannot  be  drained  into  the  cecum.  In  case  the  mucous  membrane  of 
the  narrowed  portion  is  edematous  because  of  acute  inflammation,  there  is  great  danger 
of  perforation. 

Fig.  12  shows  an  appendix  with  thickened  wall  and  gangrenous  mucous  membrane,  which 
is  in  great  danger  of  perforation. 


GENERAL  SURGERY  OF  THE  ABDOMEN  241 

It  may  also  be  displaced  upwards  and  backwards  in  which,  instance  the 
cecum  is  in  a  position  to  furnish  perfect  protection;  or  upwards  and  forward 
when  the  omentum  will  be  able  to  surround  it  on  all  sides. 

Thus  we  see  that  the  natural  anatomical  arrangement  for  the  protection 
of  the  general  peritoneal  cavity  is  extremely  efficient.  There  is  but  one  weak 
point  in  the  anatomical  provision  for  this  protection,  namely,  in  the  direction 
of  the  median  line,  because  the  great  mobility  of  the  small  intestines  naturally 
favors  the  distribution  of  septic  material  to  all  parts  of  the  peritoneal  cavity. 
If  we  can  prevent  the  small  intestines  from  doing  harm  in  this  direction,  we 
will  have  accomplished  our  end,  theoretically  at  least. 

At  this  juncture  let  us  direct  attention  to  another  important  anatomical 
condition.  The  blood  supply  of  the  omentum  is  so  enormous  that  it  will  readily 
dispose  of  a  very  severe  infection  hy  walling  off  the  surrounding  structures 
if  it  is  permitted  to  give  its  physiological  attention  to  a  single  area. 

It  is  a  well-known  fact,  which  every  one  who  frequently  operates  during 
the  acute  attack  of  appendicitis  has  had  many  opportunities  to  observe,  that 
the  omentum  crowds  itself  about  any  inflammatory  or  traumatic  lesion  within 
the  peritoneal  cavity  the  moment  such  lesion  occurs,  and  if  left  undisturbed 
a  few  hours  will  suffice  to  cause  efficient  protective  adhesions.  These  adhesions 
'become  stronger  every  hour  and  the  blood  supply  in  the  omentum  becomes 
greater,  so  that  if  no  disturbance  arises  one  can  reasonably  expect  efficient 
protection  to  the  general  peritoneal  cavity  from,  the  omentum. 

Another  important  fact  must  not  be  lost  sight  of  in  this  connection,  viz. : 
that  the  surrounding  structures  being  relatively  fixed  in  position  favor  the 
condition  of  rest  of  the  inflamed  part  and  permit  the  omentum  to  act  after 
the  manner  of  a  splint  applied  to  an  inflamed  joint.  The  value  of  rest  as  a 
preventive  to  the  extension  of  an  infection  in  any  part  of  the  body  cannot 
be  overestimated.  Consequently,  if  it  is  possible  for  us  to  secure  this  condi- 
tion of  rest  we  have  gained  another  important  point  in  the  right  direction. 

Should  the  appendix  be  displaced  upwards  its  position  is  even  more 
favorable,  because  the  available  amount  of  omentum  is  thus  increased.  Again, 
if  the  appendix  is  retro-cecal  in  its  position,  which  is  very  frequently  the 
case,  the  infection  of  the  general  peritoneal  cavity  is  more  easily  prevented 
than  when  in  its  normal  location.  If  anteriorly  misplaced  it  is  likely  to  be 
fastened  to  the  anterior  abdominal  wall  by  the  adherent  omentum. 

Peristaltic  motion  of  the  small  intestines.  It  is  plain,  then,  that  the  infec- 
tion of  the  general  peritoneal  cavity  must  occur  from  a  disturbance  on  the 
part  of  the  small  intestines  and  must  be  due  to  their  peristaltic  motion. 

It  is  significant  that  in  almost  all  cases  of  severe,  acute  appendicitis  the 
obstruction  to  the  passage  of  gas  and  intestinal  contents  through  the  ileo- 
cecal valve  is  one  of  the  early  symptoms,  a  condition  which  was  present 
throughout  the  attack  in  the  case  typified.  Nature  is  trying  to  prevent  this 
very  dangerous  disturbance  by  closure  of  the  ileo-cecal  valve.  We  have  a 
condition  corresponding  to  the  contraction  of  the  muscles  surrounding  an 
inflamed  joint:,  to  the  closure  of  the  eye-lids  in  conjunctivitis,  etc.  Moreover, 
the  muscles  overlying  the  appendix  becomes  tense.  Everything  tends  toward 
the  establishment  of  conditions  of  rest  in  the  vicinity  of  the  inflamed  organ. 

The  effect  of  the  introduction  of  any  kind  of  food  or  cathartic  into  the 
stomach.  It  is  a  fact  which  has  been  demonstrated  a  great  number  of  times 
that  peristalsis  does  not  occur  unless  food  or  cathartics  are  introduced  into 
the  stomach.  If  the  attack  occurs  shortly  after  a  meal  and  before  all  of  the 
food  has  passed  through  the  ileo-cecal  valve,  its  presence  may  cause  peri- 
staltic motion  in  the  small  intestines.  Upon  reaching  the  ileo-cecal  valve  the 
latter  may  prevent  its  passage  into  the  cecum,  causing  return  peristalsis,  and 
the  intestinal  contents  are  forced  back  into  the  stomach,  from  which  cavity 
again  to  be  expelled  by  vomiting,  or  again  forced  into  the  small  intestines, 


242  GENERAL  SURGERY  OF  THE  ABDOMEN 

giving  rise  to  further  peristaltic  motion.  Moreover,  it  will  give  rise  to  the 
formation  of  gas,  which  must  cause  disturbance  and  pain  in  its  attempt  to 
pass  the  ileo-cecal  valve. 

This  motion,  it  is  plain,  will  be  harmful  primarily  from  the  fact  that  it 
gives  rise  to  pain  by  disturbing  the  sensitive,  inflamed  tissues ;  and,  second- 
arily, from  its  likelihood  of  carrying  infectious  material,  with  which  the 
intestines  or  the  omentum  have  come  in  contact  in  the  vicinity  of  the  inflamed 
appendix,  to  other  parts  of  the  peritoneal  cavity. 

Besides  this  the  physiological  attention  of  the  omentum  cannot  be  directed 
to  the  single  area  of  infection,  because  other  parts  of  the  peritoneal  cavity 
require  its  protection,  and  such  portions  of  the  omentum  as  are  not  yet 
thoroughly  adherent  about  the  inflamed  appendix  are  inclined  to  be  diverted 
from  this  point. 

Theoretically,  then,  the  disturbance  which  is  to  be  feared  to  so  great  an 
extent  is  caused  by  the  presence  of  food  or  cathartics  in  the  stomach  and 
intestines,  and  its  logical  remedy  would  be  to  absolutely  prevent  the  intro- 
duction of  any  form  of  food  or  cathartics  into  the  stomach  and  the  removal 
by  gastric  lavage  of  any  portion  of  food  that  may  be  retained  in  the  stomach 
at  the  beginning  of  the  attack.  It  may  be  necessary  to  perform  gastric  lavage 
twice,  or  at  most  three  times,  in  order  to  entirely  remove  remnants  of  food 
which  may  have  regurgitated  into  the  stomach  from  the  small  intestines  by 
reason  of  return  peristalsis.  That  this  is  not  only  true  theoretically,  but  also 
in  practice,  we  have  demonstrated  in  a  large  number  of  cases ;  and  many  other 
surgeons  who  have  followed  the  same  plan  of  treatment  have  informed  us 
of  the  fact  that  their  experience  has  agreed  with  ours. 

Cause  of  failures.  It  is  true  that  a  few  surgeons  have  reported  failures  with 
this  method,  but  an  investigation  of  their  treatment  in  each  instance  has  shown 
that  they  disregarded  one  of  the  three  cardinal  points  in  the  treatment.  They 
either  gave  just  a  little  liquid  food  by  mouth,  or  they  gave  some  form  of 
cathartic,  or  disturbed  the  rest  of  the  intestines  by  giving  large  enemata,  or 
they  neglected  removing  the  stomach  contents  by  gastric  lavage. 

Of  course,  the  slightest  amount  of  food  is  sufficient  to  start  peristaltic 
motion  of  the  small  intestines,  and  the  same  is  true  of  cathartics,  and  conse- 
quently if  either  of  these  features  in  the  treatment  be  omitted  one  cannot  hope 
for  the  same  results.  Even  water  given  by  mouth  will  frequently  start  peri- 
stalsis, and  when  given  rapidly  by  rectum  in  the  form  of  enemata  the  same 
harmful  effect  is  often  experienced,  while  this  is  not  the  case  if  normal  salt 
solution  be  given  by  rectum  continuously  by  the  drop  method  introduced  by 
Murphy. 

Starvation  plan  of  great  value  unqualifiedly.  It  seems  clear  that  this  plan 
of  treatment  must  be  useful,  in  any  given  case,  no  matter  what  form  of  appen- 
dicitis may  be  present,  because  in  the  milder  cases  it  will  result  in  rest  of  the 
affected  part,  and  consequently  rapid  resolution ;  in  the  severe  cases  it  will 
guard  against  mechanical  distribution  of  infectious  material ;  and  in  all  cases 
it  reduces  the  tendency  to  meteorism  and  stops  the  pain. 

We  wish,  therefore,  once  more  to  impress  every  one  who  reads  this  with 
the  important  fact  that  no  matter  what  form  of  treatment  he  may  have  decided 
to  carry  out  in  any  given  case  of  acute  appendicitis  his  patient  will  be  safer  and 
more  comfortable  and  will  make  a  more  rapid  recovery  with  fewer  complica- 
tions, if  he  makes  use,  in  addition  to  the  treatment  contemplated,  of  the  plan 
just  described. 

A  great  change  in  mortality.  There  is,  particularly,  one  class  of  patients  in 
which  we  have  found  this  treatment  of  the  greatest  value.  "We  refer  to  the 
class  in  which  the  appendix  is  gangrenous  or  perforated  and  in  which  there  is 
already  a  beginning  general  peritonitis.  These  patients  give  the  impression  of 
being  profoundly  ill.    There  is  complete  obstruction  to  the  passage  of  gas  and 


GENERAL  SURGERY  OF  THE  ABDOMEN  243 

feces.  There  is  nausea  or  vomiting  and  marked  meteorism;  the  pulse  is  small 
and  quick;  usually  there  is  high  fever,  but  the  temperature  may  be  subnormal; 
respiration  is  rapid,  superficial  and  costal,  and  the  abdominal  muscles  over- 
lying the  appendix  are  tense — conditions  corresponding  to  those  we  have  just 
clinically  outlined.  The  patient  is  in  a  state  in  which  we  formerly  operated 
at  once,  day  or  night,  as  a  last  resort,  only  to  find  that  it  was  too  late  in  more 
than  one-third  of  the  number,  the  mortality  increasing  with  the  time  that  had 
elapsed  since  the  beginning  of  the  attack. 

In  this  class  there  is  now  a  recovery  of  over  ninety  per  cent.,  and  if  all  cases 
of  acute  gangrenous  and  perforative  appendicitis  are  counted,  of  over  ninety- 
eight  per  cent.,  if  the  principles  laid  down  above  be  thoroughly  applied. 

If  peristalsis  is  inhibited,  as  it  can  usually  be,  the  infection  will  become 
circumscribed  and  the  pus  can  be  evacuated  with  safety.  Moreover,  the 
condition  we  have  just  described  is  in  itself  the  result  of  the  administration 
of  food  and  cathartics.  Had  these  patients  received  neither  food  nor  cath- 
artics from  the  beginning  of  their  attack,  the  affair  would  never  have  advanced 
to  this  dangerous  point.  This  refers  particularly  to  a  class  which  Richardson 
has  so  well  described  as  being  "too  late  for  an  early,  and  too  early  for  a  late, 
operation." 

Favorable  changes  that  occur.  If  the  plan  we  have  outlined  above  is  car- 
ried out  the  following  changes  are  quite  certain  to  occur:  The  nausea  and 
vomiting  will  cease  after  one  or  two,  or  at  most  three,  gastric  irrisrations.  The 
meteorism  and  the  pain  will  decrease  greatly  during  the  first  twelve  hours  and 
will  almost  completely  disappear  in  twenty-four  hours.  The  pulse  will  become 
slower  and  firmer  and  more  regular ;  the  breathing  deeper  and  the  patient 's 
general  appearance  will  improve  to  an  astonishing  extent.  The  temperature 
will  go  below  100°  F.  the  first  twenty-four  hours,  and  in  three  days  it  will  be 
practically  normal.  The  abdominal  muscles  will  become  soft  as  soon  as  the 
stomach  contents  have  been  removed  by  gastric  lavage. 

Usually  the  improvement  is  so  rapid  that  one  is  tempted  to  spoil  everything 
by  giving  nourishment  by  mouth,  because  the  patient's  condition  does  not  seem 
serious  enough  to  warrant  such  severe  deprivation  measures. 

That  this  form  of  treatment — which  we  have  employed  since  1892,  at 
first  only  in  selected  cases  and  later  more  and  more  generally — is  really  of 
great  value  is  shown  by  clinical  results.  Our  mortality  in  cases  of  perforative 
or  gangrenous  appendicitis  with  beginning  diffuse  peritonitis  is  less  than  one- 
fourth  as  high  as  it  was  in  the  cases  operated  at  once  upon  making  the  diagno- 
sis, and  even  in  advanced  cases  of  diffuse  peritonitis  there  has  been  a  marked 
decrease  in  the  mortality  in  our  experience. 

It  might  be  said  that  these  cases  were  not  due  to  perforative  or  gangre- 
nous appendicitis,  but  that  they  were  simply  severe  catarrhal  cases,  which  are 
known  to  result  favorably  under  any  form  of  treatment.  To  this  we  would 
respond  that  we  have  later  removed  the  appendix  in  many  of  these  cases  and 
have  almost  invariably  demonstrated  the  correctness  of  the  diagnosis. 

Gastric  lavage  imperative.  It  might  seem  impossible,  returning  to  our 
clinical  case,  to  remove  more  substance  from  the  stomach  after  she  has  vomited 
so  frequently  for  a  period  of  more  than  two  days.  Frequently  physicians  have 
considered  this  step  superfluous,  because  they  have  imagined  that  the  stomach 
must  surely  be  empty  under  these  conditions.  This  is.  however,  a  very  serious 
error.  The  fact  that  the  patient  is  suffering  from  nausea  or  vomiting  is  the 
strongest  indication  for  the  use  of  gastric  lavage,  because  the  nausea  is  caused 
by  the  presence  of  decomposing  material  in  the  stomach  and  its  removal  must 
result  in  the  greatest  benefit.  It  frequently  happens  that  these  patients  lose 
their  anxious  expression  and  restlessness,  and  that  the  skin  becomes  Avarm  and 
moist  and  they  begin  to  sleep  directly  after  the  gastric  lavage  has  been 
practised. 


244 


GENERAL  SURGERY  OF  THE  ABDOMEN 


Were  a  person  in  perfect  health  to  place  in  his  stomach  the  amount  of  de- 
composing food  and  mucus  which  we  have  just  washed  out  of  the  child's 
stomach,  he  would  at  once  become  violently  ill,  and  consequently  the  eflfect 
of  this  substance  upon  a  patient  whose  strength  has  been  exhausted  bj'  a  severe 
acute  illness  must  certainly  be  still  worse.  It  is  possible  that  there  may  be 
more  material  of  the  same  character  in  the  small  intestines,  but  if  so  it  will 
soon  regurgitate  into  the  stomadi  and  makf  its  ])r('s(Mice  known  by  the  recur- 


Abdojiinal  Wound 

Represents  a  furtlier  stej)  in  the  closure  of  McBurney's  incision,  the  fascia  of  the  internal 
o})li(iiie  abdominal  muscle  having  been  united  with  a  continuous  catgut  suture. 

rence  of  nausea.  Should  this  occur  the  gastric  lavage  should  be  repeated  at 
once.  If  no  food  is  given  by  mouth  we  have  never  been  compelled  to  irrigate 
the  stomach  more  than  three  times  in  the  same  patient,  and  usually  one  care- 
ful, thorough  irrigation  will   suffice. 

Technique  of  lavage.  It  will  be  wise  to  direct  attention  to  the  method  em- 
ployed in  such  cases.  The  patient  is  turned  upon  the  right  side  in  order  to 
add  the  weight  of  the  intestines  to  the  support  of  any  adhesions  which  may 


GENERAL  SURGERY  OF  THE  ABDOMEN  245 

exist  in  the  vicinity  of  the  appendix.  The  head  and  shoulders  are  slightly 
elevated  by  means  of  pillows  or  a  head-rest,  or  by  elevating  the  head  of 
the  bed  from  thirty  to  fifty  cm.,  then  the  pharynx  is  sprayed  with  a  four  per 
cent,  solution  of  cocain  in  order  to  prevent  gagging  when  the  stomach  tube  is 
passed,  because  this  might  disturb  the  adhesions  in  the  vicinity  of  the  appendix. 
It  is  well  to  spray  the  pharynx  repeatedly  for  a  period  of  about  five  minutes, 
permitting  the  patient  to  swallow  a  little  of  the  saliva  mixed  with  cocain  in 
order  to  anesthetize  the  esophagus  to  some  extent  at  the  same  time.  Not  more 
than  one  teaspoonful  of  the  cocain  solution  should  be  placed  in  the  atomizer,  in 
order  to  avoid  harm  from  cocain  poisoning.  After  holding  the  cocain  in  the 
pharynx  a  minute  it  is  expectorated  with  the  saliva  which  has  accumulated 
and  a  fresh  spray  is  applied.  As  most  of  the  cocain  is  thus  thrown  out  there 
is  no  danger  from  poisoning.  After  about  five  minutes  a  fairly  large  stomach 
tube  is  inserted  and  the  contents  of  the  stomach  siphoned  out.  The  stomach 
tube  should  have  one  or  two  lateral  openings  aside  from  the  opening  at  its 
end.  These  openings  should  be  within  one  to  two  inches  from  the  end  which 
is  inserted  in  the  stomach.  This  will  prevent  the  end  of  the  tube  from 
becoming  closed  by  drawing  into  it  a  portion  of  the  mucous  lining  of  the 
stomach. 

Whenever  there  is  any  interruption  in  the  flow  this  may  be  overcome  by 
pouring  a  little  water  into  the  tube  and  thus  dislodging  any  substance  which 
may  have  become  fixed  therein. 

After  the  accumulation  which  was  present  in  the  stomach  has  been 
siphoned  out  it  is  well  to  introduce  into  the  stomach  a  pint  of  normal  salt 
solution  at  100°  F.  and  then  siphon  it  out.  This  may  be  repeated  until  the 
fluid  returns  clear.  It  is  well  in  these  cases  to  elevate  the  foot  of  the  bed 
about  thirty  inches  just  before  withdrawing  the  stomach  tube,  after  com- 
pleting gastric  lavage,  and  then  to  withdraw  the  tube  slowly.  In  this  manner 
it  is  possible  to  leave  the  stomach  completely  empty. 

Continuous  stomach  drainage.  A  method  of  permanent  drainage  of  the 
stomach,  in  cases  in  which  there  is  regurgitation  of  intestinal  contents  into  the 
stomach,  has  been  introduced  by  Grosser.  This  consists  in  passing  a  small- 
sized  stomach-tube  into  the  stomach  through  one  nostril  and  leaving  it  in  place 
until  no  further  accumulation  takes  place.  In  this  manner  the  irritation  and 
discomfort  due  to  the  repeated  introduction  of  the  stomach-tube  can  be 
avoided  and  the  patient  will  obtain  instant  relief  the  moment  any  substance 
is  regurgitated  into  the  stomach  without  being  subjected  to  the  harmful  effect 
of  absorption  of  a  portion  of  this  offensive  material,  which  occurs  in  the 
intervals  between  successive  gastric  lavages. 

The  quantity  of  fluid  lost  in  this  manner  is  restored  to  the  patient  by  con- 
tinuous but  very  slow  administration  of  normal  salt  solution,  or  4  per  cent, 
dextrose  solution  by  hypodermoclysis. 

The  Fowler  position.  The  patient  should  now  be  placed  in  bed  with 
shoulders  somewhat  elevated  so  as  to  favor  gravitation  toward  the  pelvis. 
The  position  introduced  by  Fowler,  which  is  accomplished  by  elevating  the 
head  of  the  bed  twenty-four  to  thirty  inches,  seems  to  be  very  useful  in  these 
cases,  and  we  have  practised  placing  our  patients  in  this  position  constantly 
since  Fowler  demonstrated  its  value.  She  should  receive  absolutely  no  food 
and  no  cathartics  by  mouth.  Every  four  hours  she  should  have  an  enema  of 
an  ounce  of  one  of  the  concentrated  predigested  foods  dissolved  in  three 
ounces  of  normal  salt  solution.  We  are  confident  that  she  will  not  require  any 
anodyne,  her  pain  will  disappear  spontaneously,  since  we  have  removed  the 
cause  of  irritation  by  performing  gastric  lavage.  It  is,  however,  perfectly 
safe  after  performing  gastric  lavage  to  give  the  patient  from  ten  to  thirty 
drops  of  deodorized  tincture  of  opium  in  each  rectal  feeding  until  the  pain  has 
completely  subsided,  should  it  oersist  after  the  gastric  lavage  has  been  com- 


246 


GENERAL  SURGERY  OF  THE  ABDOMEN 


pleted.  This  would,  of  course,  be  extremely  harmful  were  any  food  or  ca- 
thartics to  be  given.  In  the  meantime  we  will  observe  the  patient  carefully, 
because  it  is  quite  possible  that  circumscribed  abscess  may  develop  in  the  right 
inguinal  region.  If  this  should  occur  we  will  simply  drain  the  abscess.  It 
is  surprising  to  observe  how  much  infection  will  be  disposed  of  by  the  peri- 
toneum and  the  omentum,  and  how  extensive  an  infection  of  the  peritoneum 


Closure  of  Abdominal  Wound. 

Represents  the  last   step   in  the  closure  of   McBuruey's   incision,   the   deep   silkworm    gut 
sutures  and  the  coaptation  sutures  for  the  skin  having  been  applied. 

will  subside  completely,  if  one  will  only  secure  a  condition  of  rest  to  the  small 
intestines  and  thus  prevent  the  further  infection  of  the  portions  of  peritoneum 
away  from  the  point  of  primary  infection  in  the  vicinity  of  the  vermiform 
appendix. 

Exceptionally  unfavorable   cases.     There   are  two  classes  of  patients  in 
whom  this  form  of  treatment  is  not  so  satisfactory  as  it  is  in  all  others,  namely, 


GENERAL  SURGERY  OF  THE  ABDOMEN  247 

the  very  old  and  the  very  young.  Very  old  patients  do  not  bear  confinement 
in  bed  well,  no  matter  what  their  condition  may  be,  and  they  do  not  prosper 
generally  on  rectal  feeding.  In  these  cases  one  is  compelled  to  choose  between 
two  evils,  and  whichever  is  chosen  one  usually  wishes  it  had  been  the  other. 

It  should  be  stated  here  that  very  old  patients  bear  confinement  in  bed 
much  better  when  kept  in  the  Fowler  position  than  in  the  horizontal  position, 
and  since  the  introduction  of  this  feature  we  have  never  had  a  case  of  hypo- 
static pneumonia  in  one  of  these  aged  patients  because  of  their  confinement  to 
bed. 

In  children  it  is  difficult  to  perform  gastric  lavage;  they  are  likely  to 
struggle  and  injure  themselves  while  this  is  being  accomplished.  The  same 
is  true  of  administering  rectal  feeding.  Moreover,  the  omentum  in  small 
children  is  not  sufficiently  developed  to  act  as  an  efficient  protection.  It  is 
consequently  wise  in  these  two  classes,  to  operate  whenever  the  patient's  con- 
dition indicates  that  he  will  probably  recover  from  the  operation. 

Return  to  diet.  After  the  patient  has  recovered  from  the  acute  attack, 
which  can  be  determined  from  finding  the  temperature  and  pulse  normal,  the 
diminished  rigidity  of  the  abdominal  wall,  pain  and  tenderness  upon  pres- 
sure absent,  the  obstruction  to  the  passage  of  gas  and  feces  relieved,  feeding 
by  mouth  may  be  commenced  gradually.  It  is  well  to  give  a  small  cup  of  beef 
tea  made  from  some  of  the  commercial  beef  extracts  every  three  hours  at  first, 
because  this  will  serve  to  encourage  the  patient,  while  it  will  not  give  rise  to 
peristaltic  motion  as  it  is  absorbed  from  the  stomach,  being  composed  almost 
entirely  of  non-irritating  soluble  substance.  Later  milk  and  lime-water, 
soups,  broths  and  gruels  may  be  allowed.  We  believe  that  it  is  well  not  to 
operate  in  these  cases,  after  they  have  recovered  from  the  acute  attack,  until 
they  are  in  a  condition  in  which  it  seems  perfectl}^  safe  to  give  the  ordinary 
dose  of  castor  oil,  which  we  are  in  the  habit  of  administering  in  preparing 
patients  for  abdominal  operations.  Of  course  this  should  not  be  given  as  long 
as  there  is  any  doubt  regarding  the  complete  recovery,  because  if  given  too 
early  it  might  be  the  cause  of  recurrence.  If  the  oil  causes  no  disturbance  it  is 
fair  to  suppose  that  the  patient  has  fully  recovered  from  the  acute  attack  and 
is  in  a  favorable  condition  for  obtaining  radical  relief. 

Many  patients  refuse  to  be  operated  after  they  have  recovered  from  the 
acute  attack,  and  until  the  past  few  years  we  frequently  had  patients  come 
under  our  care  on  the  third  to  the  seventh  day  of  an  attack  of  acute  perforative 
or  gangrenous  appendicitis  whom  we  would  treat  through  the  acute  attack 
with  the  method  just  described,  but  who  would  refuse  operation  during  the 
interval.  Later  a  number  of  these  patients  had  recurrent  attacks  and  were 
treated  with  cathartics  or  were  operated  during  the  third  or  fourth  day  of  a 
severe  acute  attack  and  thus  lost  their  lives  unnecessarily. 

Later  appendectomy.  To  avoid  this  we  have  followed  the  plan  of  confin- 
ing these  patients  to  liquid  diet  until  the  appendix  has  been  removed,  even 
if  this  is  postponed  for  several  months.  If  they  change  to  solid  food  they 
usually  experience  some  discomfort,  and  fearing  another  acute  attack,  have 
returned  for  operation  and  in  time  to  have  an  interval  operation. 

We  have  many  times  made  the  error  of  operating  too  soon  after  an  acute 
attack,  but  never  has  the  interval  been  too  long  in  cases  in  which  the  patient 
took  nothing  but  liquids,  together  with  soft  boiled  eggs,  mush,  purees,  custards, 
boiled  rice  and  thoroughly  cooked  cereals  after  recovering  from  the  acute 
attack  until  the  interval  operation  had  been  performed. 

Confirmatory  testimony.  Since  the  publication  of  the  last  edition  of  this 
book,  thousands  of  practitioners  of  medicine  and  surgery,  and  many  distin- 
guished surgeons  who  were  not  convinced  of  the  correctness  of  our  views  con- 
cerning this  subject  at  that  time,  have  thoroughly  tested  the  method  and  have 


248  GENERAL  SURGERY  OF  THE  ABDOMEN 

either  privately  or  publicly  stated  that  by  adding  this  plan  to  their  former 
conception  of  the  indications  for  treatment  of  this  disease,  they  have  suc- 
ceeded in  reducing  their  mortality  to  a  very  marked  extent. 

Our  own  experience  has  still  further  confirmed  the  correctness  of  the  views 
expressed  in  the  former  editions.  Circumstances  have  been  such  that  we  have 
had  an  opportunity  to  demonstrate  an  enormous  number  of  these  cases  to  many 
surgeons  from  all  parts  of  this  and  other  countries,  so  that  at  the  present  time 
we  need  but  repeat  the  indications  expressed  on  this  subject  in  the  former 
editions,  viz. : 

Conclusions:  In  order  that  our  views  concerning  the  treatment  of  appen- 
dicitis ma}'  be  perfectly  understood,  we  here  repeat  the  conclusions  which  were 
formulated  some  time  ago  and  which  have  been  followed  throughout  in  the 
treatment  of  all  of  our  cases, 

1.  The  mortality  in  appendicitis  results  from  the  extension  of  infection 
from  the  appendix  to  the  peritoneum,  or  from  metastatic  infection  from  the 
same  source. 

2.  This  extension  may  be  prevented  by  removing  the  appendix  while  the 
infectious  material  is  still  confined  to  that  organ. 

3.  The  distribution  or  extension  of  the  infection  is  accomplished  by  the 
peristaltic  action  of  the  small  intestines. 

4.  It  is  also  accomplished  by  operation  after  the  infection  material  has 
extended  beyond  the  appendix  and  before  it  has  become  circumscribed. 

5.  Peristalsis  of  the  small  intestine  can  be  inhibited  by  prohibiting  the 
use  of  every  form  of  nourishment  and  cathartic  by  mouth  and  by  employ- 
ing gastric  lavage  in  order  to  remove  any  food  substances  or  mucus  from 
the  stomach. 

6.  The  patient  can  be  safelj^  nourished  during  the  necessary  period  of 
time  by  means  of  nutrient  enemata.  Large  enemata  should  never  be  given, 
for  they  may  cause  the  rupture  of  an  abscess  into  the  peritoneal  cavity. 

7.  In  case  neither  food  nor  cathartics  are  given  from  the  beginning  of  the 
attack  of  acute  appendicitis,  and  gastric  lavage  is  employed,  the  mortality  is 
reduced  to  an  extremely  low  percentage. 

8.  In  cases  which  have  received  some  form  of  food  and  cathartics  during 
the  early  portion  of  the  attack,  and  are  consequently  suffering  from  a  begin- 
ning diffuse  peritonitis  when  they  come  under  treatment,  the  mortality  will 
still  be  less  than  two  per  cent,  if  peristalsis  is  inhibited  by  gastric  lavage  and 
the  absolute  prohibition  of  all  forms  of  nourishment  and  cathartics  by  mouth. 

9.  In  this  manner  very  dangerous  cases  of  acute  appendicitis  may  be 
changed  into  relatively  harmless  ones  of  chronic  appendicitis. 

10.  In  our  personal  experience  no  case  of  acute  appendicitis  has  died 
in  which  absolutel}^  no  food  of  any  kind  and  no  cathartic  were  given  by  mouth 
from  the  beginning  of  the  attack. 

11.  The  mortality  following  operations  for  chronic  appendicitis  is  exceed- 
ingly low. 

12.  Were  peristalsis  inhibited  in  every  case  of  acute  appendicitis  by  the 
methods  described  above,  absolute  prohibition  of  food  and  cathartics  by  mouth 
and  the  use  of  gastric  lavage,  appendectomy  during  any  period  of  the  attack 
could  be  accomplished  with  much  greater  ease  to  the  operator  and  correspond- 
ingly greater  safety  to  the  patient. 

To  reduce  the  mortality  from  appendicitis.  The  following  suggestions  for 
the  treatment  of  appendicitis  are  made  with  a  view  of  reducing  the  mortality : 

1.  Patients  suffering  from  chronic  recurrent  appendicitis  should  be  oper- 
ated on  during  the  interval. 

2.  Patients  suffering  from  acute  appendicitis  should  be  operated  on  as 
soon  as  the  diagnosis  is  made,  provided  they  come  under  treatment  while 


GENERAL  SURGERY  OF  THE  ABDOMEN  249 

the  infectious  material  is  still  confined  to  the  appendix,  and  if  a  competent 
surgeon  is  available. 

3.  Aside  from  insuring  a  low  mortality  this  will  prevent  all  serious 
complications. 

4.  In  all  cases  of  acute  appendicitis,  and  in  all  cases  of  peritonitis,  without 
regard  to  the  treatment  contemplated,  the  administration  of  food  and  cathar- 
tics by  mouth  should  be  absolutely  prohibited  and  large  enemata  should  never 
be  given. 

5.  In  case  of  nausea  or  vomiting,  or  gaseous  distension  of  the  abdomen, 
gastric  lavage  should  be  employed. 

6.  In  cases  coming  under  treatment  after  the  infection  has  extended 
beyond  the  tissues  of  the  appendix,  especially  in  the  presence  of  beginning 
diffuse  peritonitis,  conclusions  four  (4)  and  five  (5)  should  always  be  employed 
until  the  patient's  condition  makes  operative  interference  safe. 

7.  In  case  no  operation  is  performed  neither  nourishment  nor  cathartics 
should  be  given  by  mouth  until  the  patient  has  been  free  from  pain  and  other- 
wise normal  for  at  least  four  days. 

8.  During  the  beginning  of  this  treatment  not  even  water  should  be  given 
by  mouth,  the  thirst  being  quenched  by  rinsing  the  mouth  with  cold  water  and 
by  the  use  of  small  enemata.  Later  small  sips  of  very  hot  water  frequently 
repeated  may  be  allowed,  and  still  later  small  sips  of  cold  water.  There  is 
danger  in  giving  water  too  freely,  and  there  is  great  danger  in  the  use  of  large 
enemata. 

9.  All  of  these  cases  are  greatly  benefited  by  the  use  of  continuous  normal 
salt  solution  by  rectum,  given  according  to  Murphy's  directions. 

10.  All  practitioners  of  medicine  and  surgery,  as  well  as  the  general  public, 
should  be  impressed  with  the  importance  of  prohibiting  the  use  of  cathartics 
and  food  by  mouth,  as  well  as  the  use  of  lar,ge  enemata,  in  cases  suffering  from 
acute  appendicitis  or  peritonitis. 

11.  It  should  be  constantly  borne  in  mind  that  even  the  slightest  amount  of 
liquid  food  of  any  kind  by  mouth  may  give  rise  to  dangerous  peristalsis  and 
may  change  a  harmless,  circumscribed  into  a  dangerous,  diffuse  peritonitis. 

12.  The  most  convenient  form  of  rectal  feeding  consists  in  the  use  of  one 
ounce  of  any  of  the  various  concentrated  liquid  predigested  foods  ,in  the  mar- 
ket, dissolved  in  three  ounces  of  warm  normal  salt  solution,  introduced  slowly 
through  a  soft  catheter,  inserted  into  the  rectum  a  distance  of  two  or  three 
inches. 

13.  This  form  of  treatment  cannot  supplant  the  operative  treatment  of 
acute  appendicitis,  but  it  can  and  should  be  used  to  reduce  the  mortality  by 
changing  the  class  of  cases  in  which  the  mortality  is  greatest  into  another  class 
in  which  the  mortality  is  very  small  after  operation. 

14.  It  is  important  to  bear  in  mind  the  fact  that  this  treatment  is  always 
indicated  without  regard  to  whether  an  immediate  operation  is  or  is  not 
contemplated. 

15.  It  is  further  important  not  to  be  deceived  by  the  very  rapid  improve- 
ment of  what  appear  to  be  serious  cases  into  the  belief  that  the  case  is  not  a 
gangrenous  or  perforative  appendicitis,  because  such  patients  may  easily  be 
killed  by  giving  food  too  early. 

Diagnosis.  In  order  to  treat  patients  suffering  from  appendicitis  with  the 
greatest  degree  of  success,  it  is  important  to  make  a  careful,  early  diagnosis. 
This  will  depend  upon  two  conditions : 

A  careful  physical  examination.  This  should  be  made  in  every  case  in 
which  there  is  any  symptom  of  intra-abdominal  disturbance.  It  has  been  our 
experience  to  find  a  mistaken  diagnosis  at  the  beginning  of  an  attack  of  appen- 
dicitis has  usually  resulted  from  the  fact  that  the  family  physician,  when  first 


250  GENERAL  SURGERY  OF  THE  ABDOMEN 

called,  was  willing  to  make  a  diagnosis  of  gastritis,  or  enteritis,  or  catarrhal 
disturbance  of  the  alimentary  canal,  from  the  symptoms  given  by  the  patient 
or  his  friends,  without  himself  making  a  physical  examination  in  order  to 
ascertain  the  actual  state  of  affairs.  This  is  true  even  more  commonly  in  chil- 
dren than  in  adults.  Until  very  recently  more  than  ninety  per  cent,  of  all 
cases  of  appendicitis  in  children  came  into  our  hospital  service  with  a  diagnosis 
of  gastritis,  and  more  than  fifty^  per  cent,  had  not  been  subjected  to  a  physical 
examination. 

Only  a  few  years  ago  more  than  fifty  per  cent,  of  all  women  entering  the 
hospital  suffering  from  appendicitis  came  with  a  diagnosis  of  tubal  infection. 
This  error  was  so  common  at  that  time  that  many  of  the  best  authors  upon 
this  subject  of  appendicitis  stated  that  the  disease  occurred  much  more  fre- 
quently in  men  than  in  women.     (Deaver,  Fowler,  Mynter,  etc.) 

A  careful  physical  examination  will,  of  course,  usually  eliminate  these 
errors,  and  will  enable  the  ph^'sician  to  prevent  the  patient  from  doing  things 
which  must  certainly  increase  the  gravity  of  the  disease,  and  which  undoubt- 
edly are  frequently  responsible  for  the  fact  that  the  correct  diagnosis  is  not 
made  until  the  patient  is  almost  or  quite  in  a  hopeless  condition.  We  would 
consequently  insist  upon  making  a  careful  physical  examination  in  every 
patient  the  first  and  most  important  step  toward  securing  proper  treatment  in 
cases  of  appendicitis. 

Clinical  experience.  Nothing  serves  so  well  to  aid  a  phj-sician  in  compre- 
hending proper  treatment  of  these  cases  as  the  observation  of  some  of  the 
various  forms  of  appendicitis  throughout  their  course,  and  especially  through 
the  necessary  operation.  This  is  true  particularly  of  physicians  practising 
internal  medicine.  One  can  really  not  have  a  clear  idea  of  the  behavior  of  a 
diseased  appendix  unless  he  has  observed  it  in  all  stages  of  disease  in  the  living 
human  body.  It  is  such  a  natural  matter  to  imagine,  when  the  acute  condition 
subsides,  that  the  amount  of  disturbance  must  have  been  slight,  that  unless 
one  has  an  opportunity  later  to  demonstrate  the  actual  condition  by  removing 
the  appendix  he  is  not  likely  to  appreciate  the  gravity  of  the  disease  in  ordi- 
nary acute  cases. 

On  the  other  hand,  unless  one  has  observed  the  intra-abdominal  condition 
during  the  acute  attack  in  some  of  the  most  desperate  cases  of  acute  perfora- 
tive or  gangrenous  appendicitis,  in  which  the  removal  of  the  organ  seemed 
impossible  even  in  the  hands  of  the  most  skillful  surgeon,  and  a  year  or  more 
subsequently  at  a  second  operation  the  almost  normal  condition  of  everything 
within  the  abdominal  cavity,  with  the  exception  of  the  appendix  itself  and 
possibly  a  few  unimportant  adhesions,  he  is  hardly  competent  to  appreciate 
what  Nature  can  accomplish  within  the  peritoneal  cavity. 

In  order  to  become  familiar  with  these  pathological  conditions  we  believe 
the  student  of  medicine  and  the  practitioner  doing  post-graduate  work  should 
observe  these  cases  before,  during  and  after  operation  in  the  great  hospitals 
where  such  examples  are  numerous,  and  they  should  study  the  pathological 
condition  in  the  living  patient.  In  the  study  of  these  processes  in  the  living 
patient  one  is  impressed  with  certain  facts  which  it  is  believed  have  a  very 
important  bearing  upon  the  treatment  of  appendicitis. 

Drainage  of  the  appendix.  So  long  as  the  appendix  is  in  a  condition  in 
which  its  lumen  is  thoroughly  drained  the  organ  will  not  cause  any  sierious 
trouble,  and  just  in  the  proportion  in  which  this  drainage  is  interfered  with 
will  the  danger  to  the  patient  increase. 

Primarily,  the  obstruction  is  always  due  to  an  inflammation,  either  directly 
because  of  the  accompanying  congestion  or  edema,  which  in  itself  may  suffice 
to  obstruct  the  cecal  end  of  the  lumen ;  or  it  may  be  that  the  first  infection 
subsides  and  leaves  a  small  ulcer  which  heals  and  causes  a  slight  amount  of 


GENERAL  SURGERY  OF  THE  ABDOMEN  251 

contraction^  and  at  the  time  of  the  next  acute  congestion  or  inflammation  this 
portion  of  the  lumen  is  already  abnormally  small  and  consequently  the  more 
easily  obstructed. 

The  moment  this  portion  of  the  lumen  becomes  completely  obstructed  a 
sudden  increase  in  the  infection  is  certain  to  occur,  and  this  will  constitute  a 
real  danger  to  the  patient.  Again,  in  many  cases  the  appendix  contains 
infected  granulation  tissue  for  a  considerable  period  of  time,  which  will  be  in 
a  condition  to  at  any  time  cause  an  obstruction  of  the  lumen  of  the  appendix 
and  thus  be  favorable  to  the  production  of  serious  trouble. 


\ 

; 

A- 

' 

--r 

B 

J ' 

/ 

/ 

'i 

c 

/ 

D 

;        

_,- 

McBuRNEY  Incision  with  Lateral  Extension. 

This  illustrates  a  case  in  which  the  typical  McBurney  incision  failed  to  give  sufficient  space 
to  safely  remove  an  adherent  appendix  and  in  order  to  secure  the  desired  space  a  second 
incision  was  made  through  the  internal  oblique  abdominal  muscle,  transversalis  fascia  and  peri- 
toneum. A,  shows  deep  silkworm  gut  suture;  B,  suture  for  peritoneum  and  transversalis  fascia; 
C,  aponeurosis  of  external  oblique  abdominis  muscle;  D,  internal  oblique  abdominis  muscle; 
E,  suture  uniting  the  cut  ends  of  the  internal  oblique  abdominis  muscle. 

Whenever  an  infection  approaches  the  surface  of  the  appendix  the  latter 
is  likely  to  become  adherent  to  the  surrounding  tissues,  and  this  in  turn  results 
in  an  obstruction  to  the  lumen  of  the  appendix  by  causing  short  bends  or  kinks. 
At  any  given  time  this  obstruction  may  become  so  complete  that  nothing  will 
drain  into  the  intestine,  and  then  there  is  grave  danger  of  gangrene  of  the 
organ  from  pressure  as  well  as  from  interference  with  the  circulation.  There 
is  the  same  difference  between  an  infected  appendix  with  free  drainage  into 
the  cecum,  and  one  in  which  this  drainage  has  been  obliterated,  that  we  find 
in  an  acute  abscess  in  any  other  portion  of  the  body  that  is  thoroughly  drained 
and  one  in  which  no  drainage  has  been  established. 

The  increased  pressure  upon  the  tissues  surrounding  an  abscess  in  anj^  por- 
tion of  the  body  will  sooner  or  later  produce  pressure-necrosis,  and  this  prob- 


252  GENERAL  SURGERY  OF  THE  ABDOMEN 

ably  accounts  for  gangrene  of  the  mucous  lining  of  severely  distended  appen- 
dices so  frequently  met  with  in  relatively  early  operation  in  severe  cases 
of  acute  appendicitis. 

Condition  of  the  appendix  after  an  acute  attack.  It  seems  most  important 
to  impress  the  clinical  fact  upon  our  minds  that  whatever  the  changes  may  be 
which  occur  in  any  given  ease  as  a  result  of  acute  or  chronic  inflammation  of 
the  appendix,  the  latter  is  rareh'  in  as  favorable  a  condition  as  regards  the 
safety  of  its  possessor  after  as  before  the  occurrence  of  this  inflammation.  The 
change  in  its  structure  is  almost  invariably  a  reduction  of  some  portion  of  its 
lumen,  and  this  necessarily  means  a  certain  degree  of  interference  with  its 
drainage,  and  this  in  turn  produces  a  tendency  to  the  recurrence  of  an  acute 
or  chronic  inflammation. 

There  are  but  two  conditions  in  which  the  above  course  does  not  obtain: 
First,  in  the  rare  case  in  which  •  a  patient  recovers  from  an  acute  attack  in 
Avhich  the  appendix  is  entirely  destroyed,  and,  second,  where  the  obliteration 
of  the  lumen  begins  at  the  distal  end  of  the  organ  and  progresses  uniformly 
toward  the  cecal  end.     This  is  also  exceedingly  rare. 

All  of  these  results  are  impressed  upon  the  surgeon  more  and  more  forcibly 
as  his  experience  increases,  and  it  seems  as  though  their  observation  should 
lead  to  methods  of  treatment  which  would  be  more  and  more  favorable  to  the 
patient. 

There  can  be  no  doubt  but  that  in  a  vast  majority  of  cases  a  vermiform 
appendix  which  has  once  been  the  seat  of  severe  inflammatory  disturbance  can 
never  thereafter  be  perfectly  normal. 

At  best,  the  normal  appendix  contains  conditions  very  favorable  for  inflam- 
matory disturbances  from  the  fact  that  it  is  a  blind,  dependent  sac  with  its 
open  end  communicating  with  the  cecum,  which  normally  always  contains 
■septic  material. 

Localization  of  the  disease.  While  so  much  can  be  said  against  this  organ, 
3^et  the  more  one  comes  in  contact  with  it  the  more  points  will  he  find  which 
seem  favorable  to  the  patient  who  possesses  a  diseased  appendix  if  the  latter 
is  removed  while  the  infection  is  still  confined  to  its  lumen.  First,  there  is, 
with  the  exception  of  a  few  very  rare  instances,  always  a  time  in  every  case  of 
appendicitis  when  all  of  the  infectious  material  is  confined  to  this  organ  and 
under  conditions  which  are  favorable  to  removal  without  appreciable  inter- 
ference with  any  other  organ.  Second,  the  appendix  is  in  an  accessible  region. 
Third,  it  is  easily  located  by  following  the  longitudinal  band  upon  the  surface 
of  the  cecum  in  a  downward  direction  until  it  is  found.  Fourth,  its  removal 
from  the  cecum  is  extremely  simple  and  when  once  removed  the  cecum  can  be 
left  smooth  and  without  any  denuded  surfaces.  In  other  words,  after  the 
appendix  has  been  removed  the  patient  is  in  no  way  physically  impaired.  This, 
however,  is  true  only  so  long  as  the  infection  is  still  confined  to  the  appendix 
itself,  a  condition  which  exists  during  the  very  beginning  of  an  acute  attack, 
and  after  a  patient  has  perfectly  recovered  from  an  acute  attack.  This  being 
the  case,  it  seems  logical  to  conclude  that  if  a  patient  comes  under  care  during 
a  time  when  he  is  in  this  condition,  it  will  be  proper  to  relieve  him  of  this  use- 
less and   dangerous  organ. 

Time  limit  of  local  infection.  In  acute  appendicitis  no  definite  time  can  be 
given  during  which  the  infection  is  probably  stjll  within  the  appendix  itself, 
but  in  severe  cases  this  may  usually  be  accepted  as  during  the  first  thirty-six 
hours  after  the  beginning  of  an  attack.  In  mild  cases  this  condition  often 
obtains  throughout  the  entire  period  of  the  acute  attack.  It  is  consequently 
important  to  use  one's  judgment,  rather  than  to  go  by  any  number  of  hours,  in 
determining  whether  the  infection  is  still  within  the  appendix. 

It  is  quite  important,  however,  to  determine  this  fact,  because  if  one  can  be 


GENERAL  SURGERY  OF  THE  ABDOMEN  253 

certain  thereof  he  can  also  be  certain  that  with  a  reasonable  amount  of  skill 
and  experience  in  abdominal  surgery  all  of  the  infectious  material  may  be 
removed  from  the  peritoneal  cavity  at  once,  leaving  the  latter  in  an  exceed- 
ingly favorable  condition  for  a  speedy  and  permanent  recovery. 

The  determining  condition  of  the  immediate  operation.  All  surgeons  with 
extensive  experience  in  the  treatment  of  appendicitis  at  the  present  time  seem 
to  agree  upon  this  one  view :  That  in  acute  appendicitis,  in  ivhich  the  patient 
comes  under  the  care  of  the  surgeon  during  a  time  when  the  infection  is  still 
confined  to  the  appendix,  an  immediate  operation  is  indicated,  provided  a  com- 
petent surgeon  is  availahle  and  the  other  conditions  necessary  for  the  successful 
execution  of  abdominal  operations  are  within  reach. 

This  is  true  for  the  following  reasons : 

1.  The  patient   is  practically   certain  to   recover. 

2.  He  will  be  able  to  resume  his  occupation  within  a  short  time. 

3.  He  cannot  have  a  recurrence. 

4.  It  practically  eliminates  complications,  such  as  adhesions,  metastatic 
abscesses,  empyema,  septic  endocarditis,  thrombo-phlebitis  and  peritonitis. 

5.  Drainage  will  be  unnecessary,  hence  there  is  no  danger  of  post-operative 
ventral  hernia. 

6.  The  infection  of  the  pelvic  organs  in  the  female,  with  their  serious  con- 
sequences, as  adhesions,  dysmenorrhea,  sterility,  ovarian  cyst,  etc.,  will  be 
avoided. 

7.  There  will  not  be  the  serious  digestive  disturbances  which  are  prac- 
tically always  present  in  patients  suffering  from  recurrent  appendicitis. 

8.  The  amount  of  suffering  will  be  reduced  to  a  minimum. 

Another  reason  which  is  commonly  mentioned  and  which  is  not  infrequently 
given  in  favor  of  an  immediate  operation,  not  only  in  this  class  of  cases,  but 
in  all  suffering  from  acute  appendicitis,  is  the  fact  that  we  are  supposed  not  to 
know  what  will  be  the  outcome  in  any  given  case  of  appendicitis.  This,  how- 
ever, is  true  only  in  cases  in  which  the  treatment  before  they  come  under  care 
has  been  improper,  and  in  which  the  future  treatment  is  likely  to  be  equallj^ 
bad. 

In  any  given  case  in  which  the  treatment  from  the  first  has  been  proper, 
and  in  which  it  will  be  equally  good  in  the  future,  we  can  predict  with  as  much 
certainty  as  in  any  disease  that  we  are  called  upon  to  treat  just  what  the  future 
will  bring.  This  is  true  because  of  the  peculiar  position  of  the  appendix  and 
because  of  its  environment. 

The  appendix  is  located  in  a  secluded  portion  of  the  peritoneal  cavity  and 
it  is  surrounded,  with  the  exception  of  the  inner  side,  by  relatively  fixed  struc- 
tures. About  it  we  find  in  front,  the  cecum ;  to  the  outer  side  and  behind,  the 
abdominal  wall ;  below,  the  pelvic  cavity ;  and  only  to  the  inner  side  have  we 
the  exceedingly  movable  small  intestines.  Aside  from  this  we  have  the  omen- 
tum, which  is  always  ready  to  care  for  a  diseased  appendix  by  placing  its  folds 
about  the  later  and  preventing  septic  material  from  infecting  any  of  the  sur- 
rounding structures. 

Nature's  protective  influences.  Our  observations  have  been  convincing 
beyond  a  doubt  that  the  tendency  of  Nature  is  to  maintain  a  condition  of  rest, 
and  thus  to  confine  the  infection  to  this  secluded  portion  of  the  peritoneum. 
Our  evidence  for  this  conclusion  lies  in  the  following  facts : 

1.  The  ileo-cecal  valve  at  once  prevents  the  passage  of  gas  and  feces. 

2.  The  nausea  and  vomiting  results  in  the  expulsion  of  at  least  a  portion 
of  the  offending  intestinal  contents. 

3.  All  of  the  available  omentum  collects  about  the  appendix. 

4.  The  contraction  of  the  abdominal  muscles  over  the  appendix  limits 
motion  in  this  portion  of  the  abdominal  cavity. 


254  GENERAL  SURGERY  OF  THE  ABDOMEN 

5.  The  right  thigh  is  frequently  flexed  to  enable  the  contraction  of  the 
iliacus  muscle  behind  the  appendix. 

6.  Whenever  the  abdomen  is  opened  in  cases  in  which  peristalsis  has  been 
inhibited  early  in  the  attack  by  making  gastric  lavage  and  then  giving  neither 
food  nor  cathartics  by  mouth,  the  appendix  is  found  virtually  surrounded  by 
parietal  peritoneum,  cecum,  cecal  end  of  ileum  and  omentum,  and  thus  it  is 
prevented  from  causing  trouble,  eyen  though  it  be  gangrenous  or  perforated. 
Moreover,  we  have  observed  that  when  Nature  is  aided  in  carrying  out  this 
tendency  to  establish  a  condition  of  rest,  it  will  result  either  in  the  absorption 
of  any  infectious  material  which  may  have  advanced  beyond  the  tissues  of  the 
appendix ;  or,  if  this  be  no  longer  possible,  it  will  result  in  the  formation  of  a 
relatively  harmless,  circumscribed  abscess,  which,  if  this  condition  of  rest  is 
maintained,  will  practically  always  either  perforate  into  the  cecum,  or  point 
toward  the  anterior  abdominal  wall  where  it  may  be  drained  easily  and  safeh^ 
or  it  will  rupture  into  the  rectum. 

There  are  a  few  exceptions  to  this  rule  which  should  be  mentioned  here. 
In  very  emaciated  patients  with  almost  no  omentum,  and  in  young  children 
in  whom  the  omentum  is  often  very  slight,  this  organ  occasionally  fails  to 
supply  the  necessary  protection. 

It  should  be  stated  at  this  point  that  circumstances  have  made  it  possible 
for  us  to  observe  an  unusually  large  number  of  cases  of  appendicitis,  which 
Ave  have  been  able  to  follow  through  the  acute  attack  and  later  been  able  to 
demonstrate  the  pathological  conditions  by  removing  the  part.  We  should  also 
state  that  in  every  case  in  which  it  was  possible  to  obtain  the  consent  of  the 
patient  we  have  removed  the  diseased  appendix  either  during  an  acute  attack, 
provided  the  patient's  condition  seemed  to  indicate  that  the  operation  could 
be  performed  safely;  or  if  this  was  not  the  case,  to  remove  it  in  the  interval 
at  the  conclusion  of  the  acute  attack. 

Review  of  an  extensive  series  of  cases.  During  the  past  few  years  since 
the  publication  of  the  following  statistics  our  results  have  improved  very 
greatly  for  several  reasons.  1.  Our  experience  has  been  vastly  increased  and 
with  this  our  judgment  has  improved  in  determining  the  conditions  which  in 
turn  served  as  indications  to  details  in  treatment.  2.  Practitioners  in  general 
do  not  at  the  present  time  give  cathartics  and  food  by  mouth  in  these  cases 
as  they  did  formerly  when  almost  every  patient  admitted  to  the  hospital  had 
previously  received  both  cathartics  and  food  by  mouth.  3.  We  admit  many 
more  patients  within  the  first  forty-eight  hours  after  the  beginning  of  the 
attack.  4.  Our  operative  technic  has  undoubtedly  improved  with  these  added 
years  of  experience.  5.  The  method  of  giving  normal  salt  solution  by  rectum 
by  the  drop  method  has  been  of  enormous  value. 

Instead  of  giving  the  newer  statistics  it  has,  however,  seemed  wise  to  repeat 
those  of  the  period  when  our  methods  were  on  probation  because  the  lessons 
from  the  blunders  made  during  this  period  seem  especially  valuable. 

In  preparing  the  preceding  editions  of  this  work  it  seemed  proper  to  make 
a  general  review  of  our  clinical  experiences  in  the  treatment  of  appendicitis 
in  the  interval,  because  our  position  concerning  this  subject  at  the  time  the 
first  edition  appeared  did  not  correspond  with  that  held  by  other  authors  at 
that  time. 

In  order  to  substantiate  the  opinion  expressed  in  the  first  edition  of  this 
volume,  we  have  reviewed  all  the  histories  of  one  thousand  consecutiver  cases 
of  appendicitis,  which  we  operated  at  the  Augustana  Hospital  during  the 
thirty-three  months  from  July  1,  1901,  to  April  1,  1904.  During  this  period  of 
time  every  patient  suffering  from  appendicitis  was  admitted,  at  any  time  of 
day  or  night,  without  regard  to  condition,  several  of  them  dying  almost  imme- 
diately upon  admission,  and  all  such  cases  are  included  in  these  statistics. 


GENERAL  SURGERY  OF  THE  ABDOMEN  255 

Of  the  cases  that  were  not  operated  only  those  who  died  were  counted  in 
this  series  of  one  thousand,  because  in  those  who  recovered  from  the  acute 
attack,  but  were  not  operated,  it  was  impossible  to  determine  the  exact 
anatomical  diagnosis. 

On  the  other  hand,  it  was  necessary  to  count  the  cases  that  died,  but  were 
not  operated,  seven  in  all,  because  the  statistics  would  otherwise  not  be  fair 
in  comparison  with  those  of  other  .surgeons,  who  might  have  operated  these 
fatal  cases.  We  would  say,  however,  that  with  possibly  one  or  two  exceptions 
these  seven  cases  were  quite  beyond  hope  when  they  entered  the  hospital. 

The  number,  one  thousand,  was  chosen  because  of  the  convenience  with 
which  one  can  grasp  statistics  based  upon  multiples  of  ten.  They  were  all 
taken  from  the  Augustana  Hospital  records,  because  we  have  all  of  the  cases 
at  this  institution  under  personal  observation  every  day ;  while  those  operated 
at  other  hospitals  we  can  observe  less  constantly. 

CLASSIFICATION 

Mortality. 
Percent- 
Cases.      Deaths,     age. 

Chronic  appendicitis  or  interval  operations 540  3  .5 

Acute  appendicitis  without  perforation 255  5  1.9 

(Of  these  six   entered   the  hospital   within  thirty   six 
hours  after  beginning  of  attack.) 
Acute   appendiaitis,   perforated  or   gangrenous,  without 

abscesses   55  0  .0 

(Of  these  five  entered  the  hospital  within  forty-eight 
hours  after  beginning  of  attack.) 

Acute  appendicitis,  perforated  with  abscess 117  4  3.4 

Acute  appendicitis  with  diffuse  peritonitis 33  10  30.0 


Total 1,000  22  2.2 

Of  the  255  acute  appendicitis  cases  without  perforation  200  were  operated 
upon  entering  the  hospital  and  55  were  treated  by  gastric  lavage  and  absolute 
prohibition  of  food  and  cathartics  of  every  kind  by  mouth,  the  nutrition  being 
accomplished  by  means  of  small  enemata.  Of  this  class  only  six  cases  entered 
the  hospital  within  thirty-six  hours  from  the  beginning  of  the  attack. 

There  were  55  cases  in  which  there  was  a  gangrenous  or  perforated  ap- 
pendix, which  were  admitted  before  an  abscess  had  formed.  Of  these  there 
were  five  who  entered  within  forty-eight  hours  after  the  beginning  of  the 
attack.  Of  the  entire  number  21  were  operated  at  once  and  34  were  first 
starved  until  they  seemed  in  a  safe  condition  for  operation.  In  most  of  these 
cases  the  appendix  was  completely  surrounded  by  the  omentum  and  held 
away  from  all  other  intra-abdominal  structures. 

Of  the  117  cases  of  acute  appendicitis,  perforative  or  gangrenous,  in  which 
an  abscess  had  formed,  39  were  operated  at  once  and  78  were  treated  by  pro- 
hibition of  all  nourishment  and  cathartics  by  mouth  until  their  condition 
seemed  sufficiently  improved  to  make  the  operation  appear  safe. 

Of  the  33  cases  entering  with  diffuse  peritonitis  resulting  from  perforative 
or  gangrenous  appendicitis,  all  were  treated  at  first  with  gastric  lavage  and 
exclusive  rectal  feeding.  Of  this  class  a  number  should  not  have  been  admit- 
ted, because  they  were  in  a  dying  condition  when  they  arrived  at  the  hospital, 
but  for  fear  of  excluding  any  case  which  might  recover,  notwithstanding  its 
apparently  hopeless  condition,  we  have  made  it  a  rule  never  to  refuse  a  patient 
suffering  from  any  acute  non-contagious  disease.     This  will  account  for  what 


256  GENERAL  SURGERY  OF  THE  ABDOMEN 

we  believe  is  at  the  present  time  rather  too  high  a  mortality  in  diffuse  peritoni- 
tis due  to  perforative  or  gangrenous  appendicitis. 

Among  the  33  cases  belonging  to  this  class  there  were  seven  which  were 
not  operated,  because  they  were  in  a  dying  condition  when  they  entered  the 
hospital,  or  because  from  the  time  of  admission  to  the  time  of  death  their 
condition  was  always  such  that,  with  previous  experience  with  similar  cases, 
operations  had  alwaj^s  terminated  fatally.  Still  these  cases  were  counted 
among  our  deaths,  in  order  to  include  the  entire  mortality  of  all  the  cases 
treated. 

It  is  plain  that  if  these  cases  were  eliminated  and  the  cases  added  in  which 
recovery  followed  non-operative  treatment,  our  percentage  of  mortality  would 
be  reduced.  We  would  thus  have  only  15  cases  in  more  than  1,000,  but  this 
would  not  be  absolutely  fair,  because  it  might  be  argued  that  the  death  in 
at  least  some  of  these  seven  cases  should  be  attributed  to  an  error  in  judg- 
ment, and  that  if  even  the  apparently  absolutely  hopeless  cases  had  been 
operated  at  once  some  of  them  might  have  recovered. 

Five  hundred  and  forty  cases  of  chronic  appendicitis:  Three  deaths.  In 
reviewing  the  histories  of  these  cases  we  find  many  interesting  facts. 

Case  1.  Among  the  three  deaths  in  five  hundred  and  forty  cases  of  chronic  appendicitis 
with  interval  operations,  we  find  that  one  case,  a  weakly,  unmarried  woman,  twenty-seven 
years  of  age,  who  had  been  ill  much  of  the  time  during  her  entire  life,  had  an  acute  attack 
of  appendicitis  two  years  before  entering  the  hospital,  and  a  second  attack  one  year  before, 
since  which  time  she  had  never  been  free  from  pain.  At  time  of  operation  the  appendix  was 
found  adherent,  13  cm.  long,  cicatricial  at  distal  end,  partially  obstructed  at  cecal  end,  con- 
taining a  small  amount  of  pus,  peh'is  secondarily  infected,  uterus  retroverted  and  adherent, 
together  with  ovaries  and  tubes,  in  pelvis.  Tubes  closed  at  distal  end  containing  small 
amount  of  pus,  removed,  round  ligaments  shortened.     No  drainage. 

Patient  died  four  weeks  after  operation  from  exhaustion,  probably  due  to  absorption  from 
raw  surface  in  pelvis.  Had  this  case  been  drained  she  would  probably  have  recovered.  This 
is  undoubtedly  also  true  if  only  the  appendix  had  been  removed.  This  was  without  doubt 
the  offending  organ,  and  it  is  believed  that  its  removal  would  have  resulted  in  a  fair  recovery, 
because  the  pelvic  organs  when  secondarily  infected  usually  show  great  recuperative  powers 
after  the  obstructed,  infected  appendix  has  been  removed. 

-  Case  2.  A  married  woman,  thirty-six  years  of  age,  having  suffered  from  puerperal  infec- 
tion after  the  births  of  two  children,  thirteen  and  fourteen  years  ago,  each  time  lasting  six 
weeks;  had  severe  attack  of  acute  appendicitis  twelve  and  a  half  years  ago,  confining  her  to 
bed  for  three  weeks.     Since  that  time  she  has  constantly  suffered  from  subacute  appondicitis. 

At  the  time  of  the  operation  pat'ent  was  in  n  "-reatlv  reduced  condition.  The  appendix 
was  club-shaped  at  distal  end  and  almost  completely  occluded  at  cecal  end,  and  contained 
several  hard,  fecal  concretions.  This  was  removed  and  also  both  tubes  and  ovaries,  which  were 
adherent  in  the  pelvis,  probably  as  a  result  of  the  puerperal  infection.  No  drainage  was 
established.  The  patient  died  on  the  fifteenth  day  after  the  operation  from  exhaustion.  The 
same  error  in  treatment  accounted  for  the  death  of  this  patient  as  of  the  previous  one. 

In  patients  who  have  been  greatly  reduced  by  long-continued  disease  it  is  not  wise  to 
operate  too  extensively,  and  if  this  is  done  drainage  should  be  used  in  order  to  relieve  them 
of  the  burden  resulting  from  the  necessity  of  absorbing  the  secretion   from  denuded  surfaces. 

Case  3.  In  this  patient,  a  woman  thirty-four  years  of  age,  the  chronic  appendicitis 
existing  for  a  period  of  nine  years  was  complicated  by  double  pyosalpinx.  Both  tubes,  the 
right  ovary  and  the  appendix,  were  removed.  The  appendix  was  18  cm.  long,  acutely  flexed 
about  its  middle  by  an  adhesion  to  the  cecum.  The  distal  end  contained  mucus  and  fecal 
matter. 

The  patient  showed  symptoms  of  intra-abdominal  hemorrhage  four  hours  after  the  opera- 
tion. She  was  reopened  hurriedly  and  it  was  found  that  the  ligature  upon  the  severely 
congested  right  broad  ligament  had  cut  through  the  ovarian  artery  and  the  patient  succumbed 
to  the  loss  of  blood. 

The  husband  of  this  patient  was  at  the  same  time  under  treatment  by  a  colleague  for 
specific  urethritis.  It  is  consequently  plain  that  the  infection  of  the  tubes  was  not  due  to 
the  appendicitis. 

This  death  was  due  to  an  avoidable  accident. 

The  three  deaths  in  this  group  would  have  been  avoided  had  the  opera- 
tion been  confined  to  the  removal  of  the  diseased  appendix.  The  amount  of 
disease  found  in  the  tubes  seemed,  however,  at  the  time,  to  indicate  their 
removal. 


GENERAL  SURGERY  OF  THE  ABDOMEN  257 

Ordinarily  in  similar  statistics  none  of  these  eases  would  be  included  in 
deaths  resulting  from  appendicitis  operations,  because  the  appendicitis  opera- 
tion had  no  relation  to  the  deaths,  but  in  these  statistics  every  case  is  counted 
in  which  the  appendix  was  removed  during  this  period  of  time  even  though 
the  other  disease  for  which  the  patient  was  operated  at  the  same  time  was  by 
far  the  most  serious  condition. 

Acute  appendicitis  without  perforation:    255  cases,  5  deaths. 

Case  1.  Married  woman,  forty-eight  years  old,  four  pregnancies,  two  abortions.  Has  had 
many  slight  attacks  of  ap^jendicitis  during  past  five  years,  accompanied  by  severe  pain,  last- 
ing from  two  to  five  hours.  Last  night  had  an  attack  more  severe  than  any  previous  one. 
Suffered  severe  pain  over  region  of  appendix  of  a  diifuse  character  when  it  commenced. 
Abdominal  walls  very  thick,  making  palpation  impossible.  Operation  at  once,  because  it 
seemed  likely  that  the  infection  would  be  found  confined  to  the  appendix.  The  appendix 
was  found  universally  adherent  behind  the  cecum,  partly  surrounded  by  the  omentum.  It 
was  removed  with  difficulty,  necessitating  a  considerable  amount  of  manipulation  of  the 
cecum  and  the  omentum.     No  drainage. 

The  patient  died  of  peritonitis  on  the  tenth  day  after  the  operation,  probably  due  to  the 
traumatism  necessary  in  the  removal  of  the  deeply  buried  appendix,  together  with  infection 
from  the  acutely  inflamed  organ. 

Had  this  patient  been  starved  during  the  acute  attack  and  operated  in  the  interval  she 
would  probably  have  recovered. 

Case  2.  This  patient,  an  emaciated  man  forty-four  years  of  age,  entered  the  hospital  at 
the  end  of  an  acute  attack,  which  had  not  been  very  severe.  He  had  suffered  from  recurrent 
attacks  of  appendicitis  at  various  intervals  for  a  period  of  about  twenty  years.  The  last 
three  attacks  had  been  more  severe  and  he  was  unable  to  recuperate  from  them.  Operated  at 
once  and  found  a  severely  congested  appendix,  club-shaped  at  the  distal  end  and  constricted 
at  the  cecal  end.  It  was  universally  adherent  to  tlie  lower  end  of  the  cecum  and  the  distal 
end,  which  contained  a  small  amount  of  pus,  was  adherent  to  the  anterior  surface  of  the 
iliacus  muscle. 

The  appendix  was  dissected  out  and  the  wound  closed.  The  patient  died  on  the  seventh 
day  from  peritonitis.  The  autopsy  showed  a  small  amount  of  cloudy  fluid  in  the  pelvis.  The 
infection  had  started  from  the  tissues  to  which  the  club-shaped  end  of  the  appendix  had 
been  adherent,  having  evidently  extended  through  the  walls  of  the  appendix  during  the  late 
acute  attack.  This  death  could  have  been  avoided  by  proper  drainage.  It  is  to  be  charged  to 
faulty  technique. 

Case  3.  Is  interesting  because  quite  unusual.  A  strong  laborer,  twenty-four  years  of 
age,  had  an  acute  attack  of  appendicitis  one  month  ago  which  lasted  one  week.  Within  two 
days  there  had  been  a  slight  recurrence,  but  it  seemed  likely  that  infection  was  confined  to 
the  appendix. 

The  operation  showed  a  congested,  edematous  appendix  coiled  upon  itself  like  a  snail, 
adherent  between  the  lower  end  of  the  cecum  and  the  mesentery  of  the  ileum,  obstructed  at 
its  cecal  end  and  containing  pus  and  feces  in  its  distal  end.  Abdomen  closed  without 
drainage. 

On  the  third  day  after  operation  there  developed  a  pneumonia,  which  progressed  in  a 
mild  form  until  the  patient  suddenly  contracted  a  pneumococcus  peritonitis,  of  which  he  died 
on  the  seventeenth  day  after  operation. 

The  anesthesia  had  been  started  with  chloroform,  which  was  changed  to  ether  just 
before  beginning  to  operate,  and  continued  with  ether  throughout. 

-  Pneumonia  is  much  more  likely  to  occur  in  cases  wherein  the  alimentary  canal  has  not 
been  thoroughly  emptied  by  a  cathartic,  hence  it  is  likely  that  this  patient  would  not  have 
died  had  we  waited  to  do  an  interval  operation. 

Case  4.  A  farmer,  thirty-four  years  old,  entered  the  hospital,  giving  a  history  of  rather 
a  severe  acute  attack  of  appendicitis  one  month  previous,  from  which  he  had  recovered  in  one 
week  with  the  exception  of  marked  tenderness  and  some  pain  over  McBurney's  point.  His 
temperature  was  normal  and  his  pulse  sixty-six  beats  per  minute.  He  was  otherwise  normal. 
The  appendix  was  universally  adherent  behind  the  cecum,  was  obstructed  at  the  cecal 
end  and  contained  bloody  j)us;  it  was  nineteen  centimeters  long  and  its  distal  end  reached 
nearly  up  to  the  liver.  The  denuded  surface  was  covered  with  peritoneum  and  the  abdomen 
closed  without  drainage.  The  patient  died  five  days  after  the  operation  from  acute  peritonitis. 
Drainage  would  have  prevented  this  death.  Dissecting  out  so  long  an  appendix  contain- 
ing pus,  before  the  acute  attack  had  completely  subsided,  without  instituting  drainage,  we 
think  showed  bad  judgment. 

Whenever  there  is  the  slightest  doubt  in  any  case  about  requiring  drainage  it  should  be 

the  rule  to  drain.     In  other  words,  when  absolutely  certain  that  drainage  is  not  needed,  close 

without  drainage;  when  in  doubt  at  all,  drain.  * 

Case  5.     A  boy  fifteen  years   of  age  became  ill  with  typhoid  fever  eight  weeks  before, 

which  lasted  five  weeks;  was  apparently  well  two  weeks  ago.     Ten  days  ago  developed  slight 


258  GENERAL  SURGERY  OF  THE  ABDOMEN 

fever  and  was  confined  to  bed  for  three  days;  then  he  was  apparently  well  until  ten  hours 
before  he  was  brought  to  the  hospital,  when  he  developed  excruciating  pains  over  the  entire 
abdomen,  which  became  more  severe  in  the  region  of  the  appendix.  When  the  family  physi- 
cian was  called  he  found  the  boy  writhing  in  pain  lying  upon  the  tioor.  He  immediately  sent 
him  to  the  hospital  with  a  diagnosis  of  probable  perforation  of  typhoid  ulcer,  with  a  possible 
diagnosis    of   acute    appendicitis. 

The  patient  was  at  once  anesthetized  with  chloroform,  then  ether  was  given  through- 
out the  operation,  which  lasted  but  twenty  minutes.  The  appendix  was  found  edematous, 
congested,  the  size  of  a  finger.  It  was  removed.  Its  walls  were  very  thick,  its  lumen  was 
occluded  at  the  cecal  end  by  the  edematous  mucous  membrane;  the  mucous  membrane  of 
the  appendix  was  gangrenous  in  a  number  of  circumscribed  spots  one  centimeter  in  diameter. 

The  patient  had  uremic  convulsions  almost  at  once  upon  recovering  from  the  anesthetic, 
which  became  more  and  more  frequent,  notwithstanding  the  use  of  hot  air  baths  and  trans- 
fusion of  normal  salt  solution.  Just  before  he  was  anesthetized  he  had  a  slight  convulsion, 
which  was  supposed  to  be  the  result  of  his  severe  suffering,  but  which  was  probably  uremic. 

In  this  case  the  indications  for  immediate  operation  were  so  strong  that  it  is  doubtful 
whether  one  could  have  improved  upon  the  treatment,  but  this  is  the  only  case  in  the  group 
of  five  that  probably  could  not  have  been  saved  with  proper  care  and  even  in  this  case,  it 
may  have  been  bad  judgment  to  undertake  operation  so  soon  after  his  recovery  from  typhoid 
fever.  Had  we  placed  him  on  proctoclysis  by  the  drop  method  and  prohibited  all  nourishment 
by  mouth,  he  would  probably  have  recovered.  In  each  one  of  the  preceding  four  cases,  the 
death  was  undoubtedly  due  to  bad  surgical  judgment  or  bad  technique. 

Conclusions.  All  of  these  patients  were  operated  immediately  upon  enter- 
ing the  hospital  because  their  condition  seemed  to  indicate  that  the  infectious 
material  was  confined  to  the  appendix.  Had  these  five  cases  been  added  to  the 
fifty-five  of  the  group  in  which  gastric  lavage  was  employed,  and  which  re- 
ceived neither  food  nor  cathartics  by  mouth,  but  were  confined  to  exclusive 
rectal  feedings,  it  is  likely  that  three  or  possibly  four  might  have  recovered. 
This  favorable  outcome  might  also  have  been  secured  had  drainage  been 
instituted. 

The  total  result  of  less  than  two  per  cent,  mortality  in  this  group  of  255 
cases  of  acute  appendicitis  is,  of  course,  eminently  satisfactory,  but  with  the 
addition  of  the  above  criticism,  it  is  believed  that  results  in  a  corresponding 
group  of  the  same  number  of  similar  cases  we  can  look  for  a  further  reduction 
in  the  mortality.  (This  prediction  was  made  more  than  twelve  years  ago  and 
our  experience  since  that  time  has  proven  the  correctness  of  the  statement. 
The  mortality  in  these  cases  is  now  less  than  one  per  cent.) 

Acute  perforative  or  gangrenous  appendicitis  v/itliout  abscess:  55  cases, 
no  deaths.  The  next  group  is  especially  interesting,  because  it  contains  fifty- 
five  cases  in  which  the  appendix  was  completely  surrounded  by  omentum  and 
in  which  this  protection  was  so  effective  that,  notwithstanding  the  presence 
of  gangrene  or  perforation,  the  infectious  material  had  remained  perfectly 
circumscribed.  In  all  of  these  patients,  without  regard  to  the  contemplated 
treatment,  food  by  the  mouth  and  cathartics  were  prohibited  at  once  upon 
admission  to  the  hospital,  gastric  lavage  was  employed,  exclusive  rectal  feed- 
ing was  instituted  and  continued  for  one  week  or  longer,  in  fact  until  they 
were  normal  as  regards  temperature,  pulse  and  pain  in  the  region  of  the  appen- 
dix. Five  of  these  cases  entered  the  hospital  within  forty-eight  hours  after 
the  beginning  of  the  attack  and  were  operated  at  once.  Sixteen  of  the  remain- 
ing cases  seemed  in  a  condition  making  an  immediate  operation  safe  and  were 
operated  at  once.  The  remaining  thirty-four  cases  were  placed  upon  exclusive 
rectal  feeding  until  their  meteorism,  pain  and  temperature  had  disappeared 
and  their  general  condition  had  improved  to  the  point  at  which  it  seemed  safe 
to  perform  the  operation.  This  occurred  in  most  cases  within  four  days  after 
admission,  while  in  others  the  interval  was  longer. 

In  this  group  of  cases  there  is  much  danger  of  supposing  that  a  wrong 
diagnosis  had  been  made  primarily,  and  that  it  would  be  safe  to  give  at  least 
liquid  food  and  possibly  cathartics  as  soon  as  the  patient  became  apparently 


GENERAL  SURGERY  OF  THE  ABDOMEN  259 

normal.  We  are  certain  that  this  error  has  cost  a  number  of  lives  and  has 
been  responsible  for  many  serious  recurrences. 

The  condition  is  not  as  rare  as  one  might  suppose,  as  55  cases  in  a  group 
of  1,000  makes  5.5  per  cent. 

Acute  perforative  or  gangrenous  appendicitis  with  peritonitis  and  abscess : 
117  cases,  4  deaths.  All  of  these  patients  entered  the  hospital  after  the  third 
day  from  the  beginning  of  the  attack.  They  had  all  received  some  form  of 
food  before  admission,  and  most  of  them  had  received  cathartics. 

Quite  a  proportion  of  these  cases  stated  that  they  had  received  no  food 
of  any  kind,  but  when  questioned  specifically  as  to  whether  they  had  not 
received  either  milk  or  broth  or  soup,  every  one  that  had  previously  affirmed 
that  no  food  at  all  had  been  taken  admitted  that  one  or  the  other  of  these 
forms  of  nourishment  had  been  given  them. 

Many  of  these  patients  were  received  in  a  desperate  condition,  with 
what  seemed  at  first  to  be  diffuse  peritonitis,  severe  distension  of  the  abdo- 
men, which  was  perfectly  tense,  nausea  and  vomiting.  The  slightest  jar  of 
the  bed  would  cause  severe  distress.  Many  of  them  had  a  bad  facial  expres- 
sion and  seemed  to  be  in  a  condition  of  shock  with  cold  perspiration  over  the 
forehead. 

It  is  in  this  class  of  cases  that  we  formerly  had  a  large  mortality,  which 
is  still  shared  by  all  surgeons  who  operate  at  once  in  every  case  of  acute  appen- 
dicitis immediately  upon  making  the  diagnosis. 

These  were  classed  by  Mynter  as  beginning  diffuse  peritonitis.  Per- 
sonally we  had  considered  them  as  belonging  to  a  class  in  which  the  primary 
diagnosis  of  severe  peritonitis  was  incorrect,  as  proven  by  the  fact  that  the 
abscess  later  became  circumscribed  ;  but  a  study  of  the  excellent  work  of 
Moszkowicz  seems  to  prove  beyond  a  doubt  that  the  peritoneum  in  these  cases 
has  a  sufficient  amount  of  resistance  to  change  an  early  diffuse  into  a  late 
circumscribed  peritonitis. 

Absorption  of  poisonous  intestinal  products.  One  very  important  point 
has  not  received  sufficient  appreciation  here — namely,  that  the  very  bad  gen- 
eral condition  of  the  patient  is  much  exaggerated  by  the  fact  that  a  great 
amount  of  decomposing  substance  is  being  absorbed  from  the  stomach  and 
small  intestines,  which  would  in  itself  suffice  to  make  an  otherwise  perfectly 
healthy  person  extremely  ill. 

The  excellent  studies  of  Maury  have  demonstrated  that  this  view  is  abso- 
lutelj^  correct ;  that  there  is  indeed  secreted  from  the  lining  of  the  duodenum 
in  these  cases  an  exceedingly  poisonous  substance,  consequently  the  benefit 
which  we  had  demonstrated  empirically,  has  now  been  confirmed  scientifically. 
These  patients  give  one  the  impression  of  having  been  poisoned  so  long  as  the 
decomposing  substance  remains  in  the  stomach. 

In  these  cases  the  localized  inflammation  in  the  region  of  the  appendix 
prevents  the  elimination  of  the  contents  of  the  stomach  and  the  small  intes- 
tines through  the  rectum,  and  thus  decomposition  is  greatly  increased,  as 
there  is  no  natural  drainage.  In  most  of  them  we  have  found  that  just  enough 
food  is  placed  in  the  stomach,  suited  for  decomposition,  to  produce  the  worst 
possible  conditions.  It  would  be  as  reasonable  to  suppose  that  a  person  would 
not  be  in  danger  of  drowning  if  he  were  submerged  beneath  but  a  small  amount 
of  water,  as  to  suppose  that  small  amounts  of  liquid  nourishment  given  by 
mouth  are  harmless,  when  one  fully  comprehends  existing  influences. 

This  is  still  further  favored  by  the  foolish  idea  that  there  can  be  nothing 
left  in  the  stomach  because  the  patient  has  vomited  incessantly  for  a  number 
of  hours.  In  many  of  the  cases  where  vomiting  had  continued  persistently 
for  hours  we  have  removed  great  quantities  of  decomposing  material,  in 
fact,  apparently  enough  to  hopelessly  poison  a  healthy  person. 


260  GENERAL  SURGERY  OF  THE  ABDOMEN 

Upon  removing  this  material  by  gastric  lavage  we  have  seen  many  patients 
improve  in  a  remarkable  way.  Frequently  the  temperature  will  become  nor- 
mal, or  nearly  so,  within  forty-eight  hours,  the  pulse  reduced  from  one  hundred 
and  twenty  beats,  or  more,  to  one  hundred,  or  less,  per  minute.  The  nausea 
and  vomiting  will  disappear  after  one  or  two,  or  at  most  three,  gastric  lavages, 
the  tympanitis  will  be  greatly  reduced,  and  not  uncommonly  it  will  be  pos- 
sible to  outline  a  swelling  in  the  region  of  the  appendix. 

Probably  it  will  never  be  possible  to  treat  this  class  of  cases  entirely  with- 
out mortality,  but  with  the  method  we  have  employed  the  mortality  has  bean 
reduced  to  less  than  3.5  per  cent.  (Since  this  was  written  our  mortality  in  this 
class  of  cases  has  been  reduced  to  less  than  two  per  cent.)  The  deaths  in  this 
class  occurred  in  the  following  four  cases : 

Case  1.  A  well-nourished  man,  thirty-two  years  of  age,  with  a  good  history,  with  the 
exception  of  some  apparently  unimportant  digestive  disturbances,  which  were,  however, 
probably  referable  to  a  chronic  appendicitis,  entered  the  hospital  on  the  fifth  day  of  an  acute 
attack.  Patient  received  no  food  from  the  beginning  of  the  attack  and  no  cathartics  during 
the  first  two  days;  on  the  third  and  fourth  days  some  liquid  food  was  given,  and  on  the  fourth 
day  a  dose  of  calomel  was  administered.  Patient  did  very  well  during  the  first  two  days, 
suffered  a  little  more  during  the  third  day  and  became  violently  ill  twenty  hours  after  the 
administration  of  calomel. 

On  admission  temperature  was  10.'?  degrees  F.  and  the  pulse  94.  He  suffered  severe  pain 
in  the  right  inguinal  region,  the  abdomen  was  severely  distended  with  gas  and  a  mass  could 
be  palpated  in  the  right  inguinal  region.  The  patient 's  facial  expression  was  bad  and  it 
seemed  as  though  the  peristalsis  caused  by  the  administration  of  the  calomel  had  produced 
an  extension  of  the  previously  circumscribed  peritonitis,  but  as  there  was  evidently  an  abscess 
present,  immediate  operation  was  performed. 

An  incision  twelve  centimeters  in  length  through  the  right  rectus  abdominis  muscle 
evacuated  nearly  a  litre  of  foul  jius.  The  abscess  was  freely  drained  mth  two  glass  drainage 
tubes  and  vnth  iodoform  gauze,  without  making  an  attempt  at  removing  the  appendix.  Death 
occurred  three  days  later  from  peritonitis. 

In  this  case  it  seems  clear  that  the  diffuse  infection  was  due  to  the  peristalsis  caused 
by  the  administration  of  calomel  on  the  fourth  day  of  the  attack.  It  may  have  been  bad 
practice  to  operate  at  once,  but  at  the  time  it  seemed  proper.  This  death  must,  of  course, 
be  charged  to  the  murderous  use  of  cathartics  in  acute  appendicitis. 

Case  2.  A  somewhat  emaciated  boy,  fourteen  years  of  age,  entered  the  hospital  on  the 
twelfth  day  after  the  beginning  of  his  attack.  During  the  first  six  days  the  attack  was  mild 
and  he  received  food  by  mouth.  During  the  last  six  days  he  had  received  only  a  small  amount 
of  liquid  nourishment  by  mouth.  Temperature,  102.2  degrees  F.  Pulse,  100.  Patient 
appeared  very  weak  and  ill,  his  abdomen  was  distended  with  gas.  For  the  first  five  days 
after  admission  exclusive  rectal  feeding  was  employed  and  the  infection  became  circum- 
scribed in  the  right  iliac  region,  reaching  a  little  beyond  the  median  line  to  the  left.  An 
incision  ten  centimeters  long  was  made  through  the  right  rectus  alidominis  muscle.  The 
appendix  was  found  perforated  at  the  distal  end.  It  was  surrounded  by  the  cecum,  the 
ileum  and  the  omentum.  The  perforation  in  the  end  communicated  with  an  abscess  containing 
several  ounces  of  pus,  which  was  carefully  evacuated  by  sponging,  then  the  appendix  separated 
from  its  adhesions  and  removed,  which  in  this  case  was  undoubtedly  the  fatal  mistake.  The 
abscess  cavity  was  drained.     The  patient  died  of  peritonitis  two  days  later. 

Had  we  used  better  judgment  in  this  case  by  simply  draining  the  abscess  and  removing 
the  appendix  later  on  in  the  interval,  the  patient  would  probably  have  recovered. 

The  additional  time  consumed,  the  increased  trauma  and  the  exposure  of  abraded  surfaces 
in  a  patient  with  slight  resistance  could  scarcely  have  resulted  differently.  Furthermore,  had 
this  patient  received  neither  food  nor  cathartics  by  mouth  from  the  beginning  of  his  attack 
he  would  undoubtedly  not  have  lost  his  life. 

Case  .S.  A  boy  six  years  of  age  entered  the  hospital  on  the  seventh  day  of  an  apparently 
mild  attack  of  acute  appendicitis.  During  the  preceding  three  years  the  patient  frequently 
complained  of  colicky  pains,  followed  by  vomiting.  These  attacks  never  lasted  more  than 
twenty-four  hours.  ' 

The  patient  had  received  liquid  diet  throughout  the  present  attack.  The  right  thigh 
was  flexed  upon  the  abdomen  and  in  the  region  of  the  appendix  a  mass  could  be  felt.  The 
abdomen  was  moderately  distended  with  gas,  the  abdominal  muscles  over  the  appendix  were 
tense.     Temperature,  101   degrees  F. ;   pidse,  100. 

The  patient  was  placed  on  exclusive  rectal  feedinjj  for  forty-eight  hours,  when  the 
abdomen  was  flat,  the  pain  had  disappeared  except  directly  over  the  appendix.  Temperature, 
99  degrees  F. ;  pulse,  90. 

An  incision  six  centimeters  long  through  the  right  rectus  abdominis  muscle  exposed  an 


GENERAL  SURGERY  OF  THE  ABDOMEN  261 

abscess  containing  about  one  ounce  of  pus  and  a  thick,  club-shaped  appendix  perforated 
at  the  end.  The  appendix  was  adherent  to  the  anterior  surface  of  the  iliacus  muscle  and 
the  abscess  was  completely  surrounded  by  the  omentum,  cecum  and  ileum.  The  pus  was 
sponged  away  without  soiling  any  tissue,  the  appendix  removed  and  the  abscess  cavity  drained 
with  iodoform  gauze  and  with  a  glass  tube. 

The  patient  progressed  normally  for  twenty-four  hours,  when  he  died  suddenly  without 
any  apparent  cause.     An  autopsy  was  not  obtainable. 

One  can  never  hope  to  eliminate  entirely  such  instances  of  death.  The  conditions 
appeared  very  favorable  for  a  rapid  and  complete  recovery  and  there  seemed  to  be  no  reason 
for  expecting  a  fatal  result. 

In  one  case  of  sudden  death  a  number  of  years  ago,  after  an  operation  for  appendicitis 
in  which  the  appendix  was  attached  to  the  iliac  vein,  the  result  occurred  from  the  loosening 
of  a  thrombus  of  the  external  iliac  vein.  It  is  possible  that  the  same  accident  happened  in 
the  present  case. 

Case  4.  A  woman  fifty-five  years  of  age,  who  entered  the  hospital  with  a  fistula  of  the 
cecum  due  to  an  acute  perforative  appendicitis,  operated  elsewhere  three  months  previously. 

The  patient's  condition  was  satisfactory  after  the  operation,  which  consisted  in  the 
closure  of  a  fecal  fistula  in  the  cecum  three  centimeters  long.  Five  weeks  after  the  operation, 
before  the  drainage  wound  had  completely  healed,  but  after  the  patient  had  been  out  of  bed 
for  one  week,  she  suddenly  developed  gangrene  of  the  right  lung,  from  which  she  died  a 
week  later. 

This  condition  undoubtedly  resulted  from  an  infarct  due  to  a  thrombus  formed  as  a 
result  of  the  disease  or  the  operation,  but  we  have  been  unable  to  trace  the  connection,  as  an 
autopsy  was  not  granted. 

Concerning  the  operations  in  all  of  these  cases  we  have  invariably  endeav- 
ored to  reduce  the  traumatism  to  a  minimum.  The  surrounding  peritoneal 
cavity  has  been  protected  with  warm,  moist  gauze  pads.  All  unnecessary 
manipulations  were  avoided.  In  case  of  circumscribed  abscess  the  appendix 
was  removed  when  it  seemed  as  though  this  could  be  accomplished  safely. 
The  above  histories  show  that  several  errors  of  judgment  occurred  in  connec- 
tion with  this  feature  in  this  series. 

Drainage  was  used  whenever  it  seemed  as  though  the  peritoneum  might 
not  be  capable  of  disposing  of  any  infection  remaining.  In  this  again  there 
were  some  fatal  errors.  It  is  much  better  to  drain  too  often  than  to  err  in  the 
opposite  direction. 

Irrigation  was  not  employed  in  any  of  these  cases  because  our  results 
have  been  less  satisfactory  when  this  means  was  frequently  employed. 

Reiteration  of  cardinal  principles  of  treatment.  It  is,  of  course,  impossible 
to  go  more  fully  into  the  histories  in  so  large  a  series  of  cases  without  making 
the  report  unduly  long  and  correspondingly  tedious.  We  believe,  however, 
that  enough  has  been  said  to  make  it  plain  that  experience  with  this  series 
of  one  thousand  consecutive  cases,  whose  treatment  was  based  upon  the  con- 
clusions previously  given,  would  justify  us  in  urging  others  to  make  use  of  the 
same  principles  in  treating  similar  cases. 

To  those  who  do  not  feel  justified  in  subjecting  their  patients  to  a  form 
of  treatment  of  which  they  have  not  personally  seen  a  practical  application 
we  would  suggest  that  they  continue  to  treat  their  cases  precisely  as  they 
have  up  to  the  present  time,  but  that  immediately  upon  being  called  to  see  a 
case  of  severe  acute  appendicitis  they  carefully  cocainize  the  pharynx  by 
spraying  with  a  two  per  cent,  solution,  then  wait  for  five  to  seven  minutes 
until  the  cocain  has  had  time  to  have  its  maximum  effect.  That  then  they 
introduce  a  stomach  tube  and  remove  any  substance  which  may  be  present 
in  the  stomach  by  irrigating  with  warm  normal  salt  solution.  That  then  no 
food  of  any  kind  whatsoever,  or  cathartics,  be  given  by  mouth  until  the  patient 
has  been  normal  for  four  days,  no  matter  whether  or  not  an  immediate  opera- 
tion be  performed.  The  nutrition  may  in  the  meantime  be  carried  on  by 
giving  a  nourishing  enema,  every  three  to  four  hours,  consisting  of  one  of 
the  various  concentrated  liquid  foods  in  the  market,  dissolved  in  three  ounces 


262  GENERAL  SURGERY  OF  THE  ABDOMEN 

of  normal  salt  solution,  through  a  catheter  inserted  into  the  rectum  a  distance 
of  two  to  three  inches. 

We  would  suggest  that  this  plan  be  followed  in  all  cases  in  which  the 
patients  or  their  friends  absoluteh^  refuse  an  operation. 

This  plan  has  now  been  practised  by  a  large  number  of  physicians  and  sur- 
g-eons,  and  all  of  those  who  have  actually  carried  out  the  principles  set  forth 
in  the  above  conclusions  have  found  a  very  marked  reduction  in  their  mor- 
tality. We  have  received  a  large  number  of  letters  from  physicians  testifying 
to  this  fact,  and  many  others  have  personally  reported  equally  satisfactory 
results. 

Our  own  experience  and  observation  is  borne  out  by  many  others  to  the 
effect  that  the  administration  of  any  form  of  nourishment  or  cathartics,  or 
both,  by  mouth  has  caused  an  enormous  number  of  deaths  in  patients  suft'ering 
from  acute  appendicitis,  and  that  its  prohibition  will  save  a  correspondingly 
large  number  of  lives. 

We  have  been  informed  by  many  physicians  that  before  this  method  was 
introduced  in  their  practice  they  had  many  deaths  from  acute  appendicitis 
and  that  now  they  almost  never  lose  a  patient  from  this  cause.  When  we  con- 
sider the  effect  this  treatment  has  had  upon  the  enormous  number  of  these 
cases  that  have  come  under  our  observation  at  the  August  ana  Hospital  we 
readily  comprehend  these  statements. 

ACUTE  GANGRENOUS  APPENDICITIS 

Typical  case.  Patient,  twenty-seven  years  of  age,  a  bookkeeper  by  occupation,  came 
under  care  one  hour  ago.  He  was  then  in  his  residence,  a  distance  of  two  miles  from  the 
hospital,  where  he  was  seen  in  consultation  with  his  physician,  who  had  made  the  proper 
diagnosis  before  requesting  consultation.     The  patient  gives  the  following  history: 

Family  history  good.  As  a  child  he  had  suffered  from  measles,  but  was  otherwise  well. 
About  one  year  ago  he  suffered  an  attack  of  pain  in  the  right  inguinal  region,  accompanied 
l)y  vomiting  and  fever,  and  was  confined  to  bed  for  about  one  week.  Has  been  more  or  less 
constipated  during  the  past  year  and  has  had  more  or  less  weakness  and  pain  in  the  right 
inguinal  region.  This  was  always  worse  after  having  eaten  heavily.  One  week  ago  he  had 
a  severe  attack  of  pain,  accompanied  by  vomiting  and  a  slight  amount  of  fever.  He  was 
confined  to  bed  for  three  days.  For  the  following  four  days  he  was  up  and  about,  and  was 
fairly  well  this  morning  when  he  felt  a  slight  pain  before  rising.  He  ate  breakfast  and  at 
about  ten  o'clock  was  seized  with  most  violent  distress  in  the  right  inguinal  region,  accom- 
panied by  vomiting,  chills  and  fever.  Suffers  from  severe  shock,  is  still  having  severe  pain 
in  the  right  inguinal  region,  although  he  received  a  hypodermic  injection  of  one-half  grain 
of  morphia  before  coming  to  the  hospital.  In  the  region  of  McBurney's  point  there  is  a  great 
tenderness  and  the  muscles  are  extremely  rigid.  His  temperature  is  100  degrees  F.  and  pulse 
102.    There  is  no  tumor  palpable. 

Diagnosis.  We  have  here  again  a  fairly  typical  condition.  A  history  of 
a  previous  acute  attack  of  pain  in  the  right  inguinal  region,  accompanied  by 
vomiting  and  fever,  which  must  have  been  sufficiently  severe  to  leave  the 
appendix  somewhat  impaired.  It  was  not  severe  enough  to  warrant  a  diagnosis 
of  gangrenous  or  perforative  appendicitis,  but  it  might  have  been  due  to  an 
obstruction  to  the  lumen  of  the  appendix,  resulting  from  the  presence  of  an 
enterolith  or  an  ulcer  in  the  cecal  end  of  the  appendix.  The  slight  attack  a 
week  ago  might  have  been  a  repetition  of  the  same  condition. 

At  the  present  moment  the  patient  is  still  suffering,  but  not  nearly  so  much 
as  one  hour  ago  at  his  residence,  where  he  was  fairly  in  convulsions  because 
of  the  extreme  pain  in  the  region  of  McBurney's  point.  The  large  dose  of 
morphia  he  received  before  coming  to  the  hospital  serves  to  disguise  the  con- 
dition somewhat.  This,  however,  does  not  matter,  because  there  can  be  no 
doubt  concerning  the  diagnosis. 

The  extreme  violence  of  the  attack  which  occurred  about  ten  hours  ago  and 
which  has  not  subsided  since  ;  the  increase  in  his  temperature  ;  the  acceleration 


aENERAL  SURGERY  OF  THE  ABDOMEN 


263" 


ofhis  pulse  and  the  bad  appearance  of  the  patient;  the  great  rigidity  of  his 
abdominal  muscles ;  the  obstruction  to  the  passage  of  gas,  all  go  to  show  that 
he  is  suffering  from  a  gangrenous  appendicitis,  or  an  impending  perforation 
due  to  pressure  from  an  enterolith  or  the  accumulation  of  pus  in  an  obstructed 
ulcerated  appendix.  .,       ^  .  „ 

Treatment.  Only  two  forms  of  treatment  can  be  considered  m  a  case  ot 
this  character:  1.  Immediate  operation.  2.  Palliative  treatment  according 
to  the  method  employed  in  the  previous  case  by  means  of  exclusive  rectal 
alimentation  and  consequent  elimination  of  peristalsis. 

Judging  from  the  history  here  given  and  from  the  conditions  we  find  upon 
examination  it  is  reasonable  to  suppose  that  at  the  present  time,  only  ten  hours 


Constricted  Appendix. 

A  represents  the  vermiform  appendix  witli  a  constriction  near  its  cecal  end.  The  mesen- 
teriolum  extends  a  little  beyond  the  end  of  the  appendix.  The  latter  is  markedly  edematous. 
Fig  B  represents  it  laid  open,  showing  fecal  concretions  in  its  lumen,  and  also  showing  the 
constriction  near  its  cecal  end. 


after  the  beginning  of  the  attack,  the  infectious  material  is  still  confined  to 
the  appendix. 

The  following  advantages  may  be  brought  forward  in  favor  of  an  imme- 
diate operation  in  cases  like  the  one  before  us : 

1.  The  patient  will  almost  invariably  get  well ;  it  is  an  accident  if  he  does 
not  recover.  2.  He  will  be  able  to  return  to  work  in  one  month.  3.  He  cannot 
have  a  recurrence.  4.  He  cannot  have  the  complications  resulting  from 
progressive  or  metastatic  infection.  5.  There  will  be  no  adhesions  with  their 
digestive  disturbances.  6.  There  will  be  no  ventral  hernia  because  drainage 
will  not  be  required.  7.  He  will  not  become  an  invalid  because  of  one  or 
another  of  the  possible  complications. 

It  is  quite  different  one,  two  or  three  days  later  when  the  infection  has 
extended  to  the  tissues  beyond  the  appendix,  because  at  that  time  we  would 


f 
264  GENERAL  SURGERY  OF  THE  ABDOMEN 

have  to  expect  trouble  for  the  followmg  reasons :  1.  The  patient  is  not  certain 
to  recover,  even  in  the  hands  of  the  most  skillful  surgeons.  2.  His  recovery 
from  the  operation  is  likely  to  be  slow.  S.  It  ma^^  not  be  safe  to  remove  the 
appendix  after  opening  the  abdomen,  hence  a  recurrence  may  still  occur.  4. 
The  operation  may  cause  an  extension  of  the  infection.  5.  Adhesions  are 
likely  to  follow  the  operation  performed  at  this  time  because  drainage  will 
probably  be  required.  6.  For  the  same  reason  hernia  frequently  occurs  after 
operations  performed  at  this  period. 

What  can  we  expect  in  case  the  patient  is  not  operated  immediately,  but 
treated  by  the  preceding  method  described  f 

In  cases  like  the  one  before  us,  in  which  we  have  been  compelled  to  employ 
this  method  because  the  patient  or  his  friends  absolutely  refused  an  operation, 
we  have  found  the  pain  subside  rapidly  after  employing  gastric  lavage  and 
that  the  other  symptoms  decline  within  twenty-four  or  forty-eight  hours,  or  at 
the  latest  seventy-two  hours,  with  the  exception  of  the  tenderness  upon  pres- 
sure. In  some  cases  a  circumscribed  abscess  formed,  which  had  to  be  opened 
externally  or  it  ruptured  into  the  cecum.  If  permitted  to  remove  the  appendix 
later  it  would  be  found  eliminated  from  the  general  peritoneal  cavity  by  means 
of  adhesions  to  the  omentum,  the  cecum  or  the  iliacus  muscle.  If  it  was  not 
removed  later  these  patients  usually  had  recurrent  attacks  of  appendicitis. 

We  would  consequently  say  in  considering  patients  in  the  condition  of  the 
one  just  described  that  if  a  safe  surgeon  is  available  such  patients  should 
invariably  be  operated  on  at  once  for  the  reasons  given,  which  will  undoubt- 
edly become  more  apparent  as  we  proceed  with  the  operation.  It  is  for  this 
reason  that  the  family  physician  requested  consultation  with  a  surgeon  as 
soon  as  he  had  made  his  diagnosis,  and  for  the  same  reason  we  agreed  upon 
sending  this  patient  to  the  hospital  the  moment  we  had  concluded  the  consulta- 
tion. W^e  have  lost  no  time,  for  while  the  patient  was  on  the  way  to  the 
hospital  all  preparations  for  the  operation  were  made  here  so  that  we  could 
proceed  at  once. 

Technique.  The  patient  is  so  tender  that  it  will  not  be  possible  to  prepare 
the  field  of  operation  before  he  has  been  anesthetized.  AVe  will  consequently 
proceed  with  the  anesthesia  and  then  prepare  the  field  of  operation  in  the  usual 
manner,  being  extremely  careful,  however,  not  to  exercise  a  sufficient  amount 
of  force  to  complete  an  impending  perforation  of  the  appendix. 

Incision.  It  seems  safe  in  this  instance  to  make  use  of  McBurney's  incision 
described  in  connection  with  the  previous  case,  because  this  will  leave  the 
abdominal  wall  least  impaired  after  the  wound  has  healed.  Had  the  patient 
experienced  several  very  severe  attacks  of  appendicitis,  it  might  be  reasonable 
to  suppose  that  much  space  would  be  required  for  the  removal  of  the  appendix, 
which  could  not  readily  be  obtained  through  this  incision.  Should  we  find 
conditions  more  complicated  after  opening  the  abdominal  wall  than  is  to  be 
expected  from  present  indications  we  shall  still  be  able  to  secure  an  increase 
in  the  size  of  the  wound. 

It  is  not  likely  that  we  will  find  an  abscess  outside  the  appendix  directly 
underneath  the  abdominal  wall,  as  this  is  usually  accompanied  by  a  condition 
of  edema  of  the  tissues  composing  the  abdominal  wall.  Nevertheless,  it  is  wise 
to  be  exceedingly  cautious  in  making  the  incision  through  the  transversalis 
fascia  and  peritoneum,  in  order  to  avoid  injuring  the  underlying  intestines 
which  may  be  slightly  adherent  either  from  the  attack  the  patient  experienced 
a  year  ago  or  from  the  present  attack,  because  frequently  these  adhesions 
precede  the  perforation.  This  process  might  have  taken  place  during  the 
slight  attack  the  patient  had  one  week  ago. 


GENERAL  SURGERY  OF  THE  ABDOMEN  265 

Upon  opening  the  peritoneum  we  see  a  tense,  sausage-like  object  projecting 
forward  between  the  ileum  and  the  lower  end  of  the  cecum.  It  is  surrounded 
entirely  by  a  fold  of  omentum,  being  adherent  apparently  only  behind  to  the 
cecum  and  with  this  to  the  iliacus  muscle.  There  are  no  strong  adhesions  to 
the  omentum,  but  this  structure  seems  to  be  loosely  agglutinated  to  the  appen- 
dix by  means  of  a  delicate  layer  of  leucocytic  exudate.  In  stripping  away  the 
omentum  there  is  no  bleeding  and  neither  the  omentum  nor  the  appendix  is 
abraded. 

Before  attempting  to  remove  the  appendix  we  lift  up  the  abdominal  wall 
carefully  and  tampon  the  space  around  it  with  soft  pads  of  aseptic  gauze  sat- 
urated with  warm  normal  salt  solution,  in  order  to  prevent  contamination  of 
the  remaining  portion  of  the  abdominal  cavity  in  case  of  rupture  of  the  dis- 
tended appenclix.  This  leaves  the  other  portions  of  the  abdominal  cavity 
virtually  out  of  the  field  of  operation,  which  is  especially  important  in  a  case 
like  the  one  before  us,  because  we  know  that  the  appendix  contains  septic 
material  and  we  must  guard  against  its  introduction  into  the  abdominal  cavity. 
Here  we  will  carefully  dissect  up  the  appendix  from  its  distal  end,  going  very 
cautiously  and  grasping  every  bleeding  point  with  hemostatic  forceps  as  we 
proceed,  and  applying  a  fine  catgut  ligature  each  time  in  order  to  prevent 
mischief  by  pulling  upon  these  forceps. 

It  is  often  much  better  to  apply  two  pair  of  forceps  to  the  cecal  end  of  the 
appendix  and  then  cut  between  these,  thus  severing  the  appendix  from  the 
cecum.  Then  hemostatic  forceps  are  applied  successively  to  the  mesenteriolum 
and  this  severed  so  far  as  caught  in  the  grasp  of  the  forceps  with  each  succes- 
sive forceps  that  are  applied.  In  cases  in  which  the  appendix  is  adherent  to 
the  posterior  surface  of  the  cecum  this  method  is  especially  useful  in  reducing 
the  necessary  manipulations. 

The  appendix  is  extremely  tense,  and  half  an  inch  from  its  distal  end  there 
is  a  greyish,  dark,  discolored  point,  a  circumscribed  gangrene.  The  mesentery 
extends  to  the  end  of  the  appendix,  but  is  not  free.  Evidently  the  inflam- 
matory disturbance  of  one  year  ago  resulted  in  the  adhesion  which  attached 
this  mesentery  to  the  lower  end  of  the  cecum  and  to  the  iliacus  muscle.  The 
mesentery  is  so  short  that  it  is  not  possible  to  grasp  it  with  hemostatic  forceps 
or  to  ligate  it  before  cutting,  hence  it  will  be  necessary  to  dissect  loose  the 
appendix  and  to  grasp  the  mesenteric  artery  when  it  is  divided.  This  is  ligated 
directly  and  now  we  have  the  appendix  free  in  the  wound  projecting  from  the 
lower  end  of  the  cecum,  like  a  sausage,  three  and  one-half  inches  in  length 
and  three-fourths  of  an  inch  at  its  greatest  diameter.  It  is  slightly  curved 
upon  itself  and  its  walls  are  edematous.  After  surrounding  the  appendix  with 
warm,  moist  gauze  pads,  in  order  to  protect  the  wound  in  case  of  rupture,  we 
apply  two  pairs  of  narrow,  long- jawed  forceps  upon  the  cecal  end  of  the  appen- 
dix and  cut  between.  From  this  point  on  the  operation  proceeds  precisely  as 
described  in  connection  with  the  previous  case,  with  the  exception  that  a  little 
greater  care  is  exercised  in  applying  the  sutures  in  the  cecum,  because  of  the 
increased  vascularity  due  to  the  acute  congestion.  Unless  these  stitches  are 
applied  carefully  there  is  sometimes  troublesome  oozing  from  blood  vessels, 
which  are  at  other  times  too  small  to  be  noticed. 

An  examination  of  the  specimen  removed  shows  that  the  appendix  is  com- 
pletely occluded  at  its  cecal  end  on  account  of  cicatricial  contraction  due  to 
destruction  of  its  mucous  lining,  which  probably  occurred  during  the  attack 
a  year  ago.  The  appendix  contains  pus  and  mucus  and  a  slight  amount  of 
fecal  material  in  flakes.    This  seems  to  indicate  that  the  cecal  end  of  the  lumen 


266 


GENERAL  SURGERY  OF  THE  ABDOMEN 


was  not  completely  occluded  until  the  beginning  of  the  present  attack.  The 
mucous  membrane  lining  the  appendix  is  severely  congested  and  dark  and  a 
short  distance  from  the  distal  end  there  is  an  area  of  about  half  an  inch  in 
diameter  which  is  gangrenous.    The  edematous  condition  of  the  tissues  in  the 


Adherent  Appendix. 

Represents  the  cecum  together  with  the  ileum  and  the  mesentery  of  the  latter.  The 
appendix  is  bent  upon  itself  in  the  form  of  an  interrogation  point.  It  is  strongly  attached  by 
adhesions  to  the  lower  end  of  the  cecum.  The  lymph  glands  in  its  mesentery  are  greatly 
enlarged. 

walls  of  the  appendix  is  very  apparent  on  the  surface  of  the  section  we  have 
made  longitudinally  through  this  organ. 

It  is  quite  plain  that  the  removal  of  this  organ  must  be  the  proper  treat- 
ment in  cases  like  the  one  before  us,  provided  this  can  be  accomplished  safely, 


GENERAL  SURGERY  OF  THE  ABDOMEN  267 

for  the  reasons  which  have  been  given,  but  it  is  equally  plain  that  in  such  cases 
it  would  be  an  easy  matter  to  infect  the  general  peritoneal  cavity,  which  would 
of  course  be  a  very  serious  accident. 

This  case  has  developed  today  with  great  severity,  and  still  the  conditions 
we  found  were  favorable  for  the  protection  of  the  general  peritoneal  cavity 
against  infection,  had  peristalsis  been  eliminated  by  the  method  described 
previously.  The  appendix  was  surrounded  by  the  omentum  which  would  have 
disposed  of  a  great  amount  of  infection  and  would  at  least  have  protected  the 
general  peritoneal  cavity  against  infection.  It  is  likely,  then,  that  with  this 
treatment  even  so  violent  a  case  as  this  wo  aid  be  in  the  worst  instance,  has 
resulted  in  a  circumscribed  abscess  in  the  right  inguinal  region.  It  is  for  this 
reason  that  we  believe  laparotomy  should  be  performed  for  the  relief  of  acute 
appendicitis  only  when  a  safe  surgeon  is  at  hand  and  when  the  other  conditions 
are  such  as  to  make  a  recovery  fairly  certain. 

The  conditions  here  and  in  many  other  similar  instances  which  we.  have 
operated  during  the  first  thirty-six  hours  of  an  acute  attack,  show  how  ex- 
tremely dangerous  it  is  to  encourage  peristaltic  motion  of  the  small  intestines 
by  the  giving  of  food  and  cathartics  by  mouth.  Such  action  would  probably 
have  been  followed  by  a  perforation  at  the  point  at  which  the  wall  of  the 
appendix  was  gangrenous  and  this  would  have  been  followed  by  the  rapid 
distribution  of  the  infectious  material  to  distant  parts  of  the  peritoneal  cavity. 
Had  the  gangrenous  portion  been  toward  the  cecum  a  perforation  would  prob- 
ably have  taken  place  into  the  lumen  of  the  intestine,  which  would  have  been 
favorable  for  the  recovery  of  the  patient. 

Had  we  found  it  impossible  to  remove  the  appendix  safely  through  the 
incision  which  was  made  in  the  present  case  the  required  space  could  have 
been  obtained  by  cutting  the  outer  edge  of  the  fascia  covering  the  rectus 
abdominis  muscle,  which  would  have  made  it  possible  to  slide  the  inner  por- 
tion of  the  edges  of  the  internal  oblique  muscle  apart  a  considerable  distance. 
If  this  still  failed  to  give  a  sufficient  amount  of  space  the  internal  oblique 
abdominal  muscle  could  have  been  cut  at  right  angles  to  the  direction  of  its 
fibers. 

Of  course  this  incision  may  be  lengthened  indefinitely,  although  always 
done  at  the  risk  of  weakening  the  abdominal  wall  to  a  great  extent,  because  a 
muscle  once  cut  at  right  angles  to  its  fibers  can  never  be  restored  to  an  abso- 
lutely normal  condition,  but  circumstances  may  occur  which  make  it  necessary 
to  do  this  in  order  to  secure  a  sufficient  amount  of  space  to  make  the  removal 
of  an  extensively  adherent  appendix  possible. 

If  such  a  condition  is  anticipated  it  is,  of  course,  much  wiser  to  make  the 
incision  through  the  edge  of  the  right  rectus  abdominis  muscle,  as  this  com- 
mands the  field  of  operation  equally  well  and  the  incision  may  be  lengthened 
according  to  the  necessities  of  the  case,  but  if  this  has  not  been  anticipated  it 
sometimes,  though  rarely,  becomes  necessary  to  increase  the  space.  Then  the 
incision  may  be  carried  through  the  lower  or  the  upper,  or  through  both  edges 
of  the  muscle,  according  to  the  direction  in  which  increased  space  is  desired 
for  the  safe  removal  of  the  appendix  in  any  given  case.  If  this  has  been  done 
it  is  important  to  secure  a  closure  of  the  abdominal  wound,  which  w411  prevent 
the  formation  of  a  ventral  hernia. 

In  order  to  accomplish  such  a  result  we  would  suggest  the  following  steps : 
Deep  silk-worm  gut  sutures  are  first  inserted  through  all  layers  down  to,  but 
not  through,  the  transversalis  fascia.  These  stitches  are  left  untied  until  the 
buried  sutures  have  been  applied,  then  they  are  tied  over  all,  acting  simply  as 


268  GENERAL  SURGERY  OF  THE  ABDOMEN 

stay  sutures.  The  peritoneum  and  the  transversalis  fascia  are  next  sutured 
with  continuous  catgut,  great  care  being  taken  to  secure  as  perfect  coaptation 
as  possible,  because  the  transversalis  fascia  gives  valuable  support  to  the 
abdominal  wall  at  this  point  and  if  properh'  united  will  aid  greatly  in  prevent- 
ing the  occurrence  of  a  ventral  hernia.  The  transverse  incision  in  the  internal 
oblique  muscle  is  next  repaired,  making  it  as  nearly  normal  as  possible.  For 
this  purpose  we  have  used  interrupted  stitches  of  fine,  chromicized  catgut 
used  double.  Ordinary  catgut  might  be  absorbed  before  the  muscle  ends  had 
been  thoroughly  united  and  the  retraction  of  the  latter,  due  to  muscular  con- 
traction, would  leave  a  point  of  weakness  in  the  abdominal  wall. 

It  is  likely  that  in  aseptic  cases  these  muscles  will  unite  very  quickly.  We 
have  been  compelled  to  enlarge  the  abdominal  wound  in  this  manner  in  only 
a  few  cases  and  in  these  the  result  has  been  perfectly  satisfactory;  but  we 
have  a  great  aversion  toward  any  operation  which  contemplates  the  cutting 
of  abdominal  muscles  at  right  angles  and  should  not  advise  such  an  act  except 
where  the  McBurney  incision  seemed  to  be  the  best  at  the  time  the  operation 
was  begun,  but  proved  not  sufficiently  large  to  dispose  of  the  conditions  found 
after  the  abdomen  was  opened.  The  further  steps  in  the  procedure  are  the 
same  as  described  in  connection  with  the  previous  operation. 

ACUTE   APPENDICITIS   WITH   SECONDARY  INFECTION    OF   PELVIC 

ORGANS  IN  THE  FEMALE 

TypicaJ  case.  The  patient  is  a  school-girl,  sixteen  years  of  age;  has  always  enjoyed 
good  health,  having  grown  up  in  the  country.  She  menstruated  at  thirteen  years  of  age, 
and  was  without  pain  until  one  year  ago,  when  she  suffered  from  a  typical  attack  of  appendi- 
citis. Since  then  she  has  suffered  severely  during  each  menstrual  period.  She  has  had  four 
typical  attacks  of  appendicitis  during  the  past  year;  the  last  one  began  one  month  ago  and 
she  is  just  now  recovering.  Her  present  condition  is  that  of  a  very  well  nourished  girl, 
evidently  unusually  strong  and  vigorous  when  in  good  health ;  tongue  is  clear ;  appetite  good 
previous  to  recent  attack,  now  absent;  heart,  lungs  and  kidneys  normal.  A  slight  swelling  is 
perceptible  over  the  region  of  the  appendix,  also  slight  dullness  on  percussion;  vaginal  exami- 
nation cannot  be  made  as  patient  is  a  virgin.  She  has  been  nauseated,  but  has  abstained 
from  food  almost  completely  during  this  attack. 

Class  characteristics.  This  patient  belongs  to  a  class  which  is  not  at  all 
uncommon.  The  characteristic  feature  lies  in  the  fact  that  although  the  first 
attack  was  typical  of  acute  appendicitis  and  the  recurrent  attacks  were  similar 
in  character,  there  is  in  addition  a  dysmenorrheic  pain,  which  is  niore  fre- 
quently right-sided.  The  pain  may  be  so  high  in  the  abdomen  as  to  Indicate 
a  diagnosis  of  recurrent  appendicitis  with  each  menstrual  period,  but  the  fact 
that  it  occurs  regularly  at  this  time  usually  results  in  a  diagnosis  of  dysmenor- 
rhea and  is  more  commonly  attributed  to  disease  of  the  ovary  and  tube  than 
to  the  appendix.  The  fact  that  menstruation  was  painless  and  normal  previous 
to  the  primary  attack  of  appendicitis,  and  that  the  patieut  is  a  virgin,  would 
indicate  that  the  disease  must  have  begun  in  the  appendix.  It  may  still  be 
confined  to  the  appendix  and  the  exacerbation  may  be  due  to  the  congestion 
incident  to  the  changes  present  during  the  menstrual  period.  The  close  con- 
nection between  the  right  ovary  and  tube  and  the  appendix,  due  to  the  pres- 
ence of  the  appendico-ovarian  ligament  of  Clado,  would  readily  explain  the 
effect  of  this  congestion  upon  a  chronic  appendicitis.  ^Xe  have  repeatedly 
seen  eases  where  the  ceca],  end  of  the  appendix  was  almost  completely  ob- 
structed and  the  distal  end  thereof  contained  fecal  concretions  or  pus  or 
mucus  in  which  the  irritation  or  congestion  due  to  the  menstrual  period  seemed 


GENERAL  SURGERY  OF  THE  ABDOMEN  269 

to  suffice  to  cause  a  complete  obstruction  temporarily  each  month,  and  thus 
produce  a  mild  attack  of  appendicitis  without  resulting  in  a  disease  of  the 
ovary  and  tube. 

In  other  cases  in  which  the  primary  attack  of  appendicitis  is  severe 
enough  to  result  in  an  infection  extending  beyond  the  vermiform  appendix 
the  conditions  found  are  quite  different.  There  may  have  been  a  perforation 
of  the  appendix  and  some  of  the  septic  material  escaping  from  the  immediate 
vicinity  of  the  appendix  into  the  pelvis  may  there  have  been  taken  up  by 
the  fimbriated  extremity  of  the  Fallopian  tube,  through  which  it  may  have 
been  carried  in  the  direction  of  the  uterus  by  means  of  the  ciliated  epithelium 
lining  this  tube.  The  infection  may  have  been  sufficiently  violent  in  character 
to  destroy  a  portion  of  the  lining  of  this  tube,  and  thus  have  resulted  in  an 
obstruction,  or  an  adhesion  may  have  been  formed  between  the  fimbriated 
extremity  of  the  Fallopian  tube  and  the  ovary,  or  between  any  of  the  other 
pelvic  organs,  or  directly  between  the  appendix  and  the  Fallopian  tube;  all 
or  any  of  these  organs  may  have  become  adherent  to  the  omentum. 

Indications  for  operation.  The  increasing  severity  of  the  attack,  and  the 
fact  that  although  the  patient  has  recovered  from  the  last  seizure,  she  still 
has  a  perceptible  mass  in  the  region  of  the  appendix,  would  indicate  a  sufficient 
amount  of  pathological  change  to  Avarrant  the  removal  of  the  diseased  appen- 
dix. It  seems,  however,  that  the  severe  dysmenorrhea  which  has  recurred 
regularly  with  each  menstrual  period  since  the  first  attack  of  appendicitis 
should  be  seriously  considered. 

This  condition  is  undoubtedly  due  to  the  secondary  involvement  of  the 
right  ovary  and  tube.  If  the  patient  is  not  relieved  of  the  cause  of  this  severe 
suffering,  which  accurs  at  such  short  intervals,  she  will  undoubtedly  soon 
become  a  neurotic  wreck,  because  she  will  soon  be  unable  to  recover  fully  from 
one  attack  before  the  beginning  of  the  next  one. 

It  is  also  likely  that  mam^  case's  of  sterility  result  from  the  infection  of 
the  Fallopian  tubes  having  its  origin  in  an  appendicitis ;  hence  the  sooner  the 
latter  condition  is  eliminated  the  greater  the  likelihood  of  averting  such  a 
result.  This  seems  of  sufficient  importance  to  influence  our  plan  of  treatment 
of  acute  or  recurrent  appendicitis  in  young  girls.  The  possibility  of  involve- 
ment of  the  pelvic  organs,  with  their  special  complications,  should  demand 
the  removal  of  the  diseased  appendix  more  imperatively  than  in  male  children. 

AYe  have  also  observed  many  times  that  these  children  were  badly  de- 
veloped physically  and  mentalh'  when  they  came  under  care  for  the  removal 
of  an  appendix  Avhich  had  been  diseased  to  a  slight  extent  for  several  years. 
The  history  would  show  that  there  had  been  little  or  no  progress  in  the 
child's  physical  and  mental  development  for  several  months  or  years.  Many 
of  these  cases  develop  rapidly  after  removing  the  diseased  appendix,  often 
times  gaining  more  in  six  months  than  they  had  in  the  previous  two  or  three 
years. 

In  many  patients  suffering  from  ovarian  cysts  we  have  found  the  remnants 
of  an  appendix,  once  perforated  or  partly  destroyed  by  gangrenous  appendi- 
citis. It  is  possible  that  the  cicatricial  tissue  which  formed  upon  the  surface 
of  the  ovary  because  of  the  peritonitis  in  this  vicinity  secondary  to  the  appendi- 
citis may  be  responsible  for  the  formation  of  some  of  these  cysts. 

The  same  is  true  of  extra-uterine  pregnane}^,  although  in  this  condition 
there  is  more  commonly  a  history  of  an  infection  of  the  Fallopian  tubes 
through  the  uterine  cavity. 


CO  JS 


GENERAL  SURGERY  OF  THE  ABDOMEN  271 

Technique.  In  this  case  it  seems  wise  to  make  the  incision  through  the 
outer  edge  of  the  right  rectus  abdominis  muscle,  because  we  may  require  a 
considerable  amount  of  space  through  which  to  safely  remove  an  extensively 
adherent  appendix.  Moreover,  it  may  be  desirable  to  remove  the  right  ovary 
and  tube  if  they  are  sufficiently  involved  to  make  their  complete  recovery  to 
normal  unlikely.  This  incision  can  be  made  as  short  as  desirable  until  the 
conditions  have  been  determined,  and  then  it  may  be  lengthened  upward 
or  downward  as  indicated  by  the  circumstances. 

The  mass  which  we  were  able  to  palpate  through  the  abdominal  wall 
consists  of  the  omentum  surrounding  the  appendix  and  the  lower  end  of  the 
cecum,  and  adherent  to  the  lower  end  of  this  mass  we  find  the  right  Fallopian 
tube,  which  is  closed  at  its  fimbriated  extremity,  and  the  ovary,  which  is 
severely  congested  and  twice  the  size  of  the  left  ovary,  which  is  free  and 
normal. 

In  order  to  prevent  an  infection  of  the  surrounding  portions  of  the  peri- 
toneum we  tampon  these  away  with  a  large  piece  of  moist  aseptic  gauze.  It 
is  now  one  month  since  the  beginning  of  the  last  attack,  consequently  the 
pus  which  may  be  present  is  not  likely  to  contain  any  very  virulent  micro- 
organisms. It  is,  nevertheless,  wise  to  take  the  same  precautions  against  an 
infection.  We  will  now  proceed  to  follow  the  longitudinal  band  on  the 
anterior  surface  of  the  cecum  as  the  most  reliable  guide  to  the  location  of 
the  appendix,  being  careful  to  do  as  little  mischief  as  possible  in  loosening 
the  adhesions. 

As  we  loosen  the  omentum  a  small  quantity  of  pus  is  beginning  to  escape, 
which  we  sponge  away  with  great  care  before  there  is  any  chance  of  causing 
an  infection.  The  abscess  contains  about  half  an  ounce  of  pus  and  a  fecal 
concretion  the  size  and  shape  of  an  olive  stone,  and  the  perforated  appendix 
which  is  constricted  at  the  cecal  end  and  somewhat  club-shaped  at  its  distal 
end.  AVe  ligate  the  portion  of  the  omentum  which  helps  to  form  the  abscess 
wall  and  treat  the  appendix  as  in  the  previous  cases,  after  carefully  separating 
it  from  its  adhesions  to  the  lower  end  of  the  cecum,  to  the  anterior  surface  of 
the  iliacus  muscle  and  to  the  right  ovary  and  Fallopian  tube,  which  have  been 
involved  secondarily.  When  the  perforation  of  the  appendix  occurred  some  of 
the  pus  evidently  escaped  into  the  pelvis  and  was  taken  up  by  the  fimbriated 
extremity  of  the  Fallopian  tube,  becoming  infected.  The  fimbriae  became 
adherent  to  each  other  and  to  the  ovary,  and  to  the  lower  end  of  the  adherent 
mass. 

Occasionally  it  is  better  to  sever  the  appendix  at  its  cecal  end  and  to 
invert  the  stump  and  close  the  defect  in  the  cecum  as  described  in  the  previous 
operations,  and  then  to  enucleate  the  appendix,  because  in  this  man.ner  the 
cecum  may  be  pushed  out  of  the  way  and  more  room  gained,  which  will  serve 
to  facilitate  the  enucleation.  The  same  method  may  sometimes  be  employed 
for  the  removal  of  an  infected  Fallopian  tube  and  ovary,  the  enucleation  being 
started  from  the  uterine  side,  the  tube  being  first  severed  at  the  uterine  end 
and  then  enucleated  from  within  outward. 

In  enucleating  the  inflamed  adherent  appendix  it  is  important  to  bear  in 
mind  the  fact  that  the  appendicular  artery,  which  is  found  in  the  remnant 
of  the  mesenteriolum  of  the  appendix,  is  a  vessel  of  considerable  size,  and 
that  a  fatal  hemorrhage  may  occur  if  this  vessel  is  not  thoroughly  controlled. 
The  tissues  are  often  so  fragile  that  it  is  difficult  to  grasp  this  artery  with 
hemostatic  forceps  without  crushing  it  off  and  thus  increasing  the  hemor- 
rhage. If  this  fact  is  borne  in  mind,  however,  it  is  possible  to  grasp  this 
vessel  and  ligate  it  safely. 

Ordinarily,  all  of  these  steps  may  be  carried  out  safely  if  the  wound  is 
made  sufficiently  long  to  permit  the  operation  to  be  performed  in  plain  sight ; 


272 


GENERAL  SURGERY  OF  THE  ABDOMEN 


if  the  other  portions  of  the  peritoneal  cavity  are  carefully  tamponed  away ;  if 
the  appendix  is  located  without  unnecessary  manipulations  by  using  the 
longitudinal  band  on  the  anterior  surface  of  the  cecum  as  a  guide  and  if  the 
entire  operation  is  performed  without  unnecessary  manipulation. 

With  increasing  experience  each  surgeon  learns  to  recognize  his  own  ability 


Adherent  Appendix. 

Represents  the  vermiform  appendix  bent  upon  itself,  making  several  sharp  angles,  held 
in  position  upon  the  lower  end  of  the  cecum  by  strong  adhesions,  one  of  the  latter  extending 
over  upon  the  ileum.  The  end  of  the  appendix  is  free.  The  mesenteriolum  is  narrow,  Taut  it 
extends  to  the  end  of  the  appendix. 


in  these  procedures  and  can  determine  with  a  fair  degree  of  certainty  how 
much  he  can  safely  undertake  to  do  in  any  given  case. 

It  would,  of  course,  be  much  better  simply  to  drain  the  abscess  and  later 
to  remove  the  appendix,  than  to  do  the  thorough  operation,  if  this  seemed 
safer  in  any  given  case,  because  a  second  operation  for  the  removal  of  the 
appendix  could  be  very  safely  performed  at  a  future  time.  This,  however, 
must  be  left  to  the  judgment  of  the  surgeon  who  happens  to  perform  the 
operation,  as  the  point  to  be  determined  is  not  what  is  the  best  treatment 


GENERAL  SUEGERY  OF  THE  ABDOMEN  273 

for  such  cases  in  general,  but  what  is  the  best  treatment  for  the  case  under 
consideration  with  the  skill  and  experience  at  hand.  The  general  principle, 
however,  is  applicable  to  these,  as  to  all  cases  in  surgery,  that,  other  things 
being  equal,  the  more  thorough  the  operation,  the  better. 

Drainage.  Although  we  have  removed  this  appendix,  the  infected  omen- 
tum, the  ovar}^  and  the  tube  without  contaminating  any  other  portion  of  the 
peritoneum,  and  although  we  have  apparently  removed  all  infectious  material, 
the  question  whether  or  not  it  is  wise  to  drain  must  still  be  considered.  The 
fact  that  an  abscess  has  existed  makes  drainage  permissible.  In  our  own  work 
we  drain  much  less  frequently  now  than  in  former  years,  yet  when  there  is  the 
slightest  doubt  in  any  given  case  we  always  drain. 

Should  we  drain  in  this  case  through  any  portion  of  the  abdominal  wound 
which  extends  through  the  edge  of  the  right  rectus  abdominis  muscle  a  hernia 
would  very  likely  result,  because  the  connective  tissue  formed  in  the  closure 
of  the  drainage  opening  would  be  very  likely  to  give  way.  AVe  consequently 
make  a  little  incision  ohe  inch  in  length  parallel  to  the  fibers  of  the  external 
oblique  muscle  two  inches  to  the  right  of  McBurney's  point.  This  incision 
is  carried  through  the  fibers  of  the  external  oblique  muscle  down  to  the  internal 
oblique,  the  fibers  of  which  extend  at  right  angles  to  the  former.  These  are 
also  separated  and  then  a  small  opening  is  made  in  the  transversalis  fascia 
and  peritoneum.  Through  this  opening  we  carry  a  glass  drainage  tube, 
covered  with  one  or  more  layers  of  iodoform  gauze,  to  a  point  .just  below  the 
cecum,  from  which  the  abscess  was  removed.  "What  is  left  of  the  omentum 
is  then  carried  over  this  surface  and  then  the  tampons  are  removed  and  the 
abdominal  wall  is  closed  in  the  usual  manner. 

After-treatment.  The  drainage  tube  is  removed  any  time  between  the 
second  and  the  fifth  day,  and  the  gauze  one  or  two  days  later,  when  the  drain- 
age wound  is  permitted  to  heal.  Having  been  made  without  cutting  any 
muscle  fibers,  this  wound  will  never  cause  a  hernia,  because  the  edges  of  the 
split  fibers  will  be  drawn  together  as  a  result  of  muscular  contraction,  and 
thus  the  small  opening  will  be  efficiently  and  permanently  closed. 

For  the  first  three  days  the  patient  will  be  sustained  entirely  by  m~eans 
of  rectal  feeding,  nutrient  enemata  being  given  every  four  hours,  as  described 
before.  If  the  patient  is  normal  at  the  end  of  this  time  a  moderate  amount 
of  liquid  nourishment  will  be  given  by  mouth  at  regular  intervals,  but  if  not 
normal  at  the  end  of  this  period  the  exclusive  rectal  alimentation  will  be 
continued.  In  case  of  pain  morphia  can  be  safely  given,  preferably  by  hypo- 
dermic injection  so  long  as  no  food  is  given  by  mouth. 

Complications.  In  a  few  cases  we  have  seen  both  ovaries  and  tubes,  as  well 
as  the  uterus  and  bladder,  involved  secondarily  in  acute  perforative  appendici- 
tis. The  treatment  must,  of  course,  contemplate  the  relief  of  all  of  these  com- 
plications. 

"Where  it  is  apparent,  before  the  abdomen  has  been  opened,  that  both 
ovaries  and  tubes  are  secondarily  involved,  it  is  usually  wise  to  choose  the 
median  incision,  because  from  this  the  affected  parts  can  all  be  reached,  except 
when  the  appendix  is  adherent  to  the  posterior  surface  of  the  cecum.  However, 
we  have  never  encountered  one  of  these  cases  with  a  secondary  involvement 
of  both  ovaries  and  tubes  in  which  the  diseased  condition  of  these  organs  could 
not  be  recognized  by  a  vaginal  examination.  In  that  ease  the  median  incision 
would,  of  course,  be  chosen. 

In  order  to  emphasize  its  importance  once  more,  it  is  suggested  that  in 
all  intra-abdominal  operations  performed  for  the  relief  of  dysmenorrhea,  espe- 
cially if  this  is  more  strongly  marked  on  the  right  side,  it  is  wise  to  examine 
the  appendix,  because  very  frequently  a  diseased  appendix  is  the  sole  cause  of 
dysmenorrhea. 


274  GENERAL  SURGERY  OF  THE  ABDOMEN 

In  one  instance  in  which  there  was  a  free  discharge  of  pus,  filled  with 
colon  bacilli,  from  the  vagina,  we  found  that  the  fimbriated  extremity  of  the 
right  Fallopian  tube  had  grasped  the  gangrenous  end  of  the  appendix  and 
that  this  end  had  never  healed,  so  that  a  continuous  tube  extended  from  the 
cavity  of  the  cecum  to  the  cavity  of  the  uterus, 

APPENDICITIS  IN  CHILDREN 

There  are  certain  features  in  connection  with  appendicitis  in  young  children 
which  require  especial  attention,  for  if  looked  upon  from  the  same  standpoint 
as  in  adults  our  results  will  not  attain  the  highest  degree  of  satisfaction. 

History.  Frequently  a  child  that  has  been  in  most  excellent  health,  whose 
general  appearance  indicates  no  disturbance,  whose  nutrition  is  good,  and 
who  is  in  no  way  suffering,  suddenly  develops  a  most  violent  attack  of  acute 
appendicitis.  This  can  be  explained  in  the  following  manner :  The  appendix 
in  these  children  is  usually  large,  but  the  cecal  end  is  much  the  narrowest 
portion  of  the  lumen.  This  favors  the  formation  of  an  enterolith,  which 
eventually  either  obstructs  the  cecal  end  of  the  lumen  and  brings  about  an 
acute  appendicitis  or  it  causes  an  ulcer,  resulting  from  pressure-necrosis,  with 
the  same  ultimate  result. 

In  many  the  mesentery  of  the  appendix  is  very  short,  which  still  further 
facilitates  necrosis  of  the  portion  projecting  beyond  the  end  of  the  mesentery, 
because  in  case  of  a  thrombosis  of  one  of  the  vessels  in  this  portion  there  can 
be  no  compensatory  circulation,  while  this  can  readily  be  established  when 
the  mesentery  extends  to  the  end  of  the  appendix. 

Diagnostic  error.  One  peculiarity  of  appendicitis  in  children  is  the  fact 
that  the  attack  is  almost  always  looked  upon  by  the  parents  and  friends,  and 
frequently  by  the  physician,  as  a  case  of  violent,  acute  gastritis  or  enteritis, 
resulting  from  some  indiscretion  in  eating.  (In  most  cases  the  little  patient 
has  indeed  eaten  an  unreasonable  amount  of  some  especially  indigestible  sub- 
stance just  before  the  attack  began).  This  is  so  common  that  one  rarely  sees 
these  young  appendicitis  patients  in  whom  the  correct  diagnosis  was  made 
from  the  beginning  of  the  attack. 

The  omentum  in  young  children  is  very  small  and  not  very  substantial, 
hence  it  cannot  be  of  as  much  use  in  separating  the  diseased  appendix  from 
the  general  peritoneal  cavity  as  in  the  adult,  and  consequently  it  is  necessary, 
in  cases  which  come  too  late  for  an  early  operation,  to  watch  closely  from 
day  to  day,  and  if  a  circumscribed  abscess  forms  to  drain  it. 

Another  difficulty  encountered  in  the  treatment  of  children  is  their  fear 
of  the  stomach  tube.  It  is  important  to  employ  gastric  lavage,  but  many 
willful  and  badly  brought-up  children  will  struggle  so  violently  against  its 
use  that  even  with  cocain  anesthesia  one  may  not  be  able  to  accomplish  the 
task  without  danger  of  injuring  the  patient  because  of  the  struggle  required. 
By  pinning  the  child  into  a  large  sheet  which  passes  around  the  entire  body 
from  its  neck  to  its  feet  and  placing  the  child  on  its  right  side,  it  is  usually 
possible  to  make  gastric  lavage  safely. 

To  a  slighter  extent  the  same  difficulties  are  sometimes  encountered  in 
rectal  feeding. 

The  most  important  point,  however,  is  in  dispelling  the  idea  that  a  severe 
pain  in  the  region  of  the  stomach  in  children,  coming  on  after  taking  indi- 
gestible food,  is  due  to  gastritis  and  is  consequenth^  of  little  importance,  because 
so  often  a  careful  examination  will  demonstrate  it  to  be  a  gangrenous  or 
perforated  appendicitis.  This  condition  frequently  occurs  in  children  not 
more  than  four  years  of  age.  "We  have  seen  a  number  of  cases  much  younger, 
one  as  young  as  seven  months,  and  the  accompanying  history  of  a  case  observed 


GENERAL  SURGERY  OF  THE  ABDOMEN 


275 


by  Dr.  W.  B.  Helm,  of  Rockford,  Illinois,  which  is  quoted  because  of  its  unusual 
interest,  shows  that  it  may  occur  in  those  still  younger. 


This  patient,  a  boy  three  months  old,  was  seen  by  Dr.  Helm,  January  5,  1902.  He  had 
suffered  almost  constantly  since  birth,  crying  much  of  the  time,  night  and  day.  Frequent 
tenesmus,  although  bowels  were  easily  regulated.     The  mother 's  milk  did  not  agree  and  various 


Abdominal  Incison. 

_  Eepresents  the  method  of  applying  interrupted  sutures  in  order  to  restore  the  internal 
oblique  abdominal  muscle,  in  the  same  ease  the  external  oblique  being  held  out  of  the  way  by 
means  of  retractors. 

prepared  foods  were  tried.  The  child  took  food  ravenously,  but  never  seemed  satisfied.  There 
was  no  gain  in  weight  and  some  fever  persisted  most  of  the  time.  When  the  child  was  five 
weeks  of  age  the  local  physician  was  called  and  detected  a  right  oblique  inguinal  hernia. 
There  was  apparently  no  trouble  in  reducing  it  and  he  tried  various  forms  of  retentive  appa- 
ratus. Still  the  crying,  straining  and  fever  continued.  Seven  weeks  later  the  patient  began 
to  fail  rapidly,  and  Dr.  Helm  found  it  with  a  temperature  of  103°  F.  and  pulse  varying  from 
160  to  190.  The  child  weighed  only  eight  pounds  and  still  cried  most  of  the  time.  There 
was  a  hernial  protrusion  the  size  of  a  small  hen's  egg.     The  bulk  of  the  mass  could  be  readily 


276  GENERAL  SURGERY  OF  THE  ABDOMEN 

returned,  but  a  small  object  in  the  inguinal  canal  remained.  It  seemed  like  an  undescended 
testicle,  but  both  of  these  organs  were  found  to  be  in  the  scrotum.  Repeated  trials  failed  to 
return  it  to  the  abdomen,  so  an  operation  was  advised.  On  opening  the  canal  the  doctor  found 
that  the  reducible  portion  was  the  head  of  the  colon,  and  the  irreducible  part  was  the  appendix, 
slightly  adherent  and  greatly  congested.  He  removed  the  appendix  and  closed  the  canal  by 
the  Bassini  method.  The  pain  was  apparently  lessened  at  once,  the  fever  disappeared  on  the 
third  day  and  the  child  gained  two  pounds  during  the  first  ten  days  and  made  an  uninterrupted 
recovery.  It  seems  as  though  in  this  case,  judging  from  the  history,  the  appendicitis  may 
have  been  congenital. 

In  connection  with  appendicitis  in  children,  we  believe  it  would  be  best 
to  lay  down  the  rule  that  in  every  instance  a  child  should  be  subjected  to  a 
careful  physical  examination  when  suffering  from  digestive  disturbance,  or 
from  pain  in  the  abdomen  from  any  other  supposed  cause. 

Many  of  these  children  give  a  history  of  perverted  appetites  and  of  feeling 
sick  or  nauseated  after  meals  for  some  time  before  the  acute  attack. 

APPENDICITIS  IN  OLD  PEOPLE 

Fortunately  it  is  but  seldom  that  acute  appendicitis  occurs  in  those  very 
advanced  in  years.  We  have  seen  one  case  of  perforative  appendicitis  in  a 
woman  sixty-eight  years  of  age. 

In  the  treatment  of  these  cases  the  fact  that  old  people  do  not  well  bear 
confinement  to  bed  in  the  recumbent  position  should  be  borne  in  mind.  These 
patients  should  be  placed  in  a  semi-sitting  posture  in  order  to  prevent  hypo- 
static congestion  of  the  lungs.  If  it  seems  at  all  safe  it  is  Avell  to  operate  these 
cases  at  once  in  order  to  shorten  their  confinement  as  much  as  possible.  But 
these  patients  are  usually  very  obese,  which  still  further  reduces  their  chances 
of  recoverJ^  It  is  consequently  necessary  in  every  given  instance  for  the 
surgeon  to  choose  between  two  evils,  and  the  better  his  judgment  the  more 
likely  he  will  be  to  choose  wisely.  If  the  operation  be  postponed  it  is  well  to 
reduce  the  amount  of  fat  in  the  abdominal  wall  of  obese  patients  by  proper 
treatment  and  to  remove  the  appendix  after  the  patient  has  recovered  from 
the  acute  attack.  The  method  for  reducing  the  weight  in  obese  patients  is 
discussed  fully  in  another  section, 

COMPLICATIONS  OF  APPENDICITIS 

Any  condition  which  may  result  from  infection,  either  direct  or  metastatic, 
may  result  as  an  immediate  complication  of  appendicitis.  Of  these  the  mpst 
common  is  circumscribed  or  diffuse  peritonitis,  with  or  without  the  formation 
of  abscess.  This  complication,  as  has  been  stated  before,  is  greatly  reduced 
in  its  importance  if  neither  food  or  cathartics  are  given  from  the  Ijeginning, 
because  this  eliminates  the  mechanical  distribution  of  infectious  material  by 
means  of  peristalsis.  It  also  prevents  the  disturbance  of  septic  thrombi,  which 
may  be  present  in  the  veins  at  the  seat  of  inflammation,  and  which  might 
be  loosened  were  food  and  gas  forced  through  the  ileo-cecal  valve ;  consequently 
metastatic  infection  is  also  greatly  reduced  in  this  way.  Metastatic  abscesses 
complicating  acute  appendicitis  may  develop  at  any  point  in  the  body  and 
should  be  treated  as  though  they  had  occurred  in  connection  with  the  primary 
infection. 

Many  other  complications  may  take  place,  because  the  presence  of  an 
acute  or  chronic  appendicitis  naturally  does  not  preclude  the  occurrence  of 
any  other  pathological  condition  which  might  be  present  in  a  patient  not  suffer- 
ing from  appendicitis. 

Strangulated  hernia.  A  considerable  number  of  cases  of  acute  appendicitis 
complicating  strangulated  hernia  have  been  reported.    We  have  encountered 


GENERAL  SURGERY  OF  THE  ABDOMEN 


277 


gangrenous  appendices,  both  in  strangulated  femoral  and  inguinal  herni£e,  and 
in  one  case  of  irreducible  umbilical  hernia. 

We  have  also  operated  upon  one  case  of  inguinal  hernia  which  was  com- 


Clostjre  of  McBueney  Incision. 

By  suturing  the  fascia  of  the  external  oblique  muscle  se^jarately,  as  indicated  in  this  plate, 
there  is  one  strong  layer  which  is  perfectly  restored,  which  will  compensate  for  a  portion  of  the 
defect  in  the  internal  oblique. 

The  deep  silkworm  gut  sutures  are  drawn  double.  It  is  scarcely  necessary  to  take  this 
additional  precaution,  but  the  support  from  this  source  is  undoubtedly  of  value  until  the 
injury  to  the  internal  oblique  muscle  has  had  time  to  become  repaired.  The  deep  sutures  are 
tied  after  all  of  the  layers  have  been  separately  united  with  catgut  sutures. 

plicated  with  suppurative  epididymitis  and  orchitis,  together  with  an  acute 
suppurative  appendicitis  in  a  case  of  cryptorchism.  In  this  case  the  cecum 
was  so  low  that  by  lengthening  the  herniotomy  incision  upwards  by  dilatation 
it  was  possible  to  remove  the  appendix  through  this  opening.     An  orchidec- 


278  '  GENERAL  SURGERY  OF  THE  ABDOMEN 

tomy  was  performed,  the  wound  drained  and  tamponed  with  iodoform  gauze 
for  a  week,  then  it  was  sutured  secondarily.    The  result  was  perfect. 

Typhoid  fever.  In  cities  where  typhoid  fever  is  endemic  it  is  not  a  very 
uncommon  occurrence  to  find  difficulty  in  making  a  differential  diagnosis 
between  typhoid  fever  and  a  mild  attack  of  appendicitis,  or  between  the 
presence  of  a  perforative  appendicitis  and  a  perforated  typhoid  ulcer.  In 
case  the  differential  diagnosis  between  acute  appendicitis  and  perforative 
typhoid  ulcer  cannot  be  made  positively  an  abdominal  section  is  indicated, 
because  if  the  former  condition  is  found,  this  treatment  is  proper,  while  if  the 
latter  exists  non-operative  treatment  would  almost  certainly  bring  about  a 
fatal  result. 

The  AYidal  test  ma^"  be  used  for  making  a  differential  diagnosis,  but  if  the 
patient  has  had  typhoid  fever  at  some  previous  time  the  Widal  test  will  often 
be  positive,  and  this  will  be  misleading.  Moreover  it  is  often  not  wise  to 
postpone  operative  treatment  long  enough  to  make  this  test.  It  is  also  to  be 
borne  in  mind  that  the  Widal  test  is  applicable  only  to  advanced  cases  of 
typhoid  fever,  hence,  its  value  is  greatly  reduced. 

In  several  instances  we  have  observed  patients  suffering  from  plainly 
marked  attacks  of  acute  appendicitis  in  which  a  typical  attack  of  typhoid 
fever  followed  immediately.  In  each  of  these  cases  the  patient  had  consumed 
great  quantities  of  infected  water  during  the  beginning  of  his  sickness.  The 
fever  accompanying  the  appendicitis  caused  severe  thirst,  and  the  great  quan- 
tity of  water  containing  typhoid  bacilli  consumed  during  the  time  had 
undoubtedly  brought  about  the  typhoid  infection. 

We  have,  of  course,  seen  many  cases  of  simple  appendicitis  which  had 
been  diagnosed  typhoid  fever,  and  vice  versa,  but  the  cases  referred  to  above 
did  not  belong  to  this  class. 

In  some  localities,  especially  in  great  cities,  in  which  a  large  proportion  of 
the  population  regularly  drinks  unsterilized  water  infected  with  typhoid 
bacilli,  it  is  wise  to  bear  in  mind  the  fact  that  typhoid  fever  and  appendicitis 
may  occur  at  the  same  time  in  the  same  patient.  Of  course,  the  same  thing 
might  happen  by  accident  with  almost  all  of  the  other  intra-abdominal  condi- 
tions. We  have  encountered  a  renal  calculus,  an  extra-uterine  pregnancy,  a 
gastric  ulcer,  as  well  as  all  the  varieties  of  tumors  occurring  in  the  uterus  and 
adnexa,  in  connection  with  acute  appendicitis.  It  is  likely  that  in  each  case 
the  fact  was  due  simply  to  a  coincidence  and  that  no  causal  relation  existed 
between  the  two  conditions. 

Floating  kidney.  The  presence  of  an  abnormal  mobilitj^  of  the  right  kid- 
ney, either  with  or  without  general  enteroptosis,  is  not  at  all  uncommonly 
found  in  connection  with  chronic  recurrent  appendicitis.  It  is  possible  that 
the  increased  intra-abdominal  pressure  which  has  to  be  employed  to  overcome 
the  obstruction  to  the  passage  of  gas  and  feces  through  the  ileo-cecal  valve  in 
these  cases  may  be  responsible  for  the  mobility  of  the  kidney,  or  it  may  simply 
be  a  coincidence. 

In  many  there  are  extensive  adhesions  which  interfere  seriously  with  the 
fecal  circulation,  causing  the  intestines  and  the  stomach  to  be  constantly 
distended  with  gas,  and  this  may  help  to  account  for  the  mobility  of  the  kidney. 

Thrombo-phlebitis.  Occasionally  in  cases  of  appendicitis  which  have  not 
been  operated,  and  more  frequently  following  operation,  there  is  a  thrombo- 
phlebitis of  the  external  iliac  vein.  Ordinarily  the  condition  does  not  mate- 
rially interfere  with  the  recovery.  The  same  precautions  should,  however,  be 
employed  as  in  a  thrombo-phlebitis  from  any  other  cause.  If  a  small  portion 
of  the  thrombus  is  displaced,  it  is  likely  to  cause  serious  trouble  and  may  even 
give  rise  to  an  embolism  of  the  pulmonary  artery,  causing  sudden  death.  In 
this  condition  the  greatest  danger  to  the  patient  results  from  the  fact  that 


GENERAL  SURGERY  OF  THE  ABDOMEN  279 

laymen  are  likely  to  rub  or  massage  the  affected  part  and  thus  may  loosen  a 
thrombus. 

The  part  should  be  placed  at  absolute  rest  and  under  no  circumstances 
should  rubbing  or  massage  be  permitted  over  the  affected  area. 

Pregnancy.  A  complication  which  is  usually  mistaken  for  puerperal  fever 
results  from  the  coincidence  of  an  acute  gangrenous  or  perforative  appendi- 
citis with  the  delivery  of  a  pregnant  woman.  AVe  have  observed  a  number 
of  cases  in  which  the  differential  diagnosis  could  not  be  positively  made,  but 
in  four  cases  we  were  able  to  demonstrate  gangrenous  appendices  at  the 
operation,  which  should  be  made  at  once  if  a  positive  diagnosis  can  obtain, 
and  it  seems  reasonable  to  add  that  if  the  absence  of  acute  gangrenous  appendi- 
citis cannot  be  made  with  certainty,  operation  is  justifiable. 

Carcinoma.  Primary  carcinoma  of  the  appendix  seems  to  be  sufficiently 
frequent  in  occurrence  to  require  some  consideration,  although  the  condition 
can  probably  not  be  diagnosed  until  the  abdomen  has  been  opened  and  then 
only  if  quite  advanced.  According  to  the  statistics  of  McCarthy  careful 
microscopic  examination  will  reveal  about  one-fourth  per  cent,  of  all  appendices 
surgically  removed  to  be  carcinomatous,  and  less  than  one-fourth  of  these,  or 
less  than  one  in  one  thousand,  will  be  recognized  at  the  operation  as  con- 
taining a  malignant  growth.  Our  knowledge  of  their  presence  should,  however, 
cause  the  surgeon  to  examine  each  specimen  in  order  to  insure  especially 
thorough  removal  in  case  malignancy  be  suspected. 

Hematogenous  infection  as  a  cause.  In  the  foregoing  pages,  occlusion  of 
the  lumen  of  the  appendix  is  offered  as  the  chief  etiological  factor  in  the 
production  of  this  disease.  In  our  experience  this  is  the  most  frequent  causa- 
tive factor.  Recently,  however,  Rosenow  and  other  investigators  have  brought 
forth  evidence  to  show  that  appendicitis  may  be  the  result  of  a  hematogenous 
infection,  various  pathogenic  bacteria  gaining  entrance  to  the  blood  stream 
and  then,  after  lodging  in  the  appendix,  multiplying  and  producing  an  acute 
appendicitis.  Certain  strains  of  bacteria,  especially  streptococci,  seem  to 
develop  a  definite  selective  affinity  for  certain  tissues.  Thus,  following  acute 
tonsillitis,  streptococci,  which  multiply  in  the  tonsils,  develop  a  selective  affinity 
for  lymphoid  tissue  in  other  parts  of  the  body,  and  since  the  appendix 
contains  a  large  amount  of  lymphoid  tissue,  these  organisms  may  lodge  here 
and  set  up  an  acute  inflammatory  process,  in  other  words,  an  acute  appendicitis. 

DIFFUSE  PERITONITIS 

Of  all  the  complications  of  acute  appendicitis  the  most  dangerous  is  diffuse 
peritonitis.  Moreover,  acute  perforative  and  gangrenous  appendicitis  and  its 
treatment  by  the  use  of  cathartics,  together  with  the  administration  of  some 
form  of  food  by  mouth,  or  the  operation  of  these  cases  after  beginning  diffuse 
peritonitis  has  become  established,  which  occurs  usually  in  severe  cases  from 
the  second  to  the  fifth  day,  have  given  rise  to  more  instances  of  diffuse  peri- 
tonitis than  all  other  causes  combined ;  hence  it  may  be  proper  to  discuss 
the  subject  at  this  point  and  to  emphasize  especially  the  steps  required  for  its 
prevention. 

PREVENTION  AND  INHIBITION  OF  PERITONITIS 

At  the  very  beginning  it  seems  important  to  emphasize  the  fact  that 
treatment,  must  be  directed  almost  entirely  toward  prevention  and  inhibition 
of  peritonitis,  because  this  will  reduce  the  mortality  from  this  disease  enor- 
mously. Physicians  in  general  practice  Avho  have  appreciated  this  fact  have 
almost  completely  eliminated  deaths  from  peritonitis  in  their  practice,  while 


280  GENERAL  SURGERY  OF  THE  ABDOMEN 

others  whose  attention  has  been  directed  toward  the  cure  of  peritonitis  have 
succeeded  in  reducing  their  mortality  from  this  disease  only  to  a  very  slight 
extent. 

Prevention  must  depend  largely  upon  a  careful  early  diagnosis,  and  inhi- 
bition upon  early  treatment,  in  cases  in  which  a  circumscribed  or  a  beginning 
diffuse  peritonitis  exists  when  the  patient  comes  under  the  physician's  care, 
by  definitely  planned  methods  w^hicli  will  prevent  diffusing  septic  material 
from  its  circumscribed  location  to  other  portions  of  the  peritoneal  cavity. 

There  must,  of  course,  always  be  a  certain  percentage  of  mortality  because 
some  cases  will  not  reach  the  care  of  the  physician  until  they  are  beyond 
the  period  at  which  prevention  or  inhibition  is  possible,  but  this  class  is 
constantly  decreasing  because  physicians  are  becoming  more  thorough  in 
examining  their  patients,  and  laymen  are  learning  the  importance  of  early 
intervention.  There  will  also  always  be  a  percentage  of  mortality  in  cases 
in  which  the  primary  infection  is  overwhelming,  as  in  some  •  cases  of  perfo- 
ration of  gastric,  duodenal  or  typhoid  ulcers,  or  ruptured  gall  bladder, 
although  in  all  of  these  early  closure  of  the  perforation,  sponging  away  the 
extravasated  substance  and  thorough  drainage  has  reduced  the  loss  from  this 
source  to  a  marked  degree.  Moreover,  typhoid  perforations  are  becoming 
very  scarce  in  communities  which  are  sufficiently  civilized  not  to  drink  water 
infected  with  sewerage,  and  among  those  who  will  not  permit  their  food  to  be 
infected  by  flies. 

The  mortality  from  peritonitis  at  the  present  time  is  by  far  greatest  in 
cases  in  which  the  infection  comes  from  the  vermiform  appendix  and  in  those 
of  puerperal  origin. 

Medical  literature  shows  absolutely  that  there  is  no  form  of  treatment 
of  much  use  in  peritonitis  which  is  so  far  advanced  that  the  patient  is  suffer- 
ing to  a  marked  degree  from  general  sepsis.  We  might  as  well  think  of  saving 
a  wooden  building  after  fire  has  partially  destroyed  all  the  walls  and  fioors. 
It  is  unreasonable  to  expect  good  results  under  these  conditions. 

Our  attention  must  be  directed  first  toward  prevention,  which  is  possible 
in  most  cases,  because  peritonitis  results  from  conditions  which  can  be  recog- 
nized and  permanently  relieved  before  they  have  given  rise  to  the  disease, 
by  making  a  careful  physical  examination  in  every  case  suff'ering  from  intra- 
abdominal conditions.  A  perforation  of  the  gall  bladder  is  always  preceded 
by  gastric  disturbances  which  should  result  in  a  physical  examination,  which, 
in  turn,  should  establish  a  diagnosis  of  cholecystitis  or  cholelithiasis.  An 
operation  for  the  relief  of  this  condition  would  prevent  the  perforation  and 
peritonitis. 

The  same  can  be  said  of  other  conditions  Avhich  later  result  in  peritonitis. 

Value  of  the  physical  examination.  No  physician  has  a  right  to  prescribe 
for  the  relief  of  any  intra-abdominal  condition  without  having  made  a  physical 
examination. 

The  calamity  which  may  follow  the  crime  of  a  superficial  examination 
in  chronic  cases,  after  weeks  or  months,  may  follow  after  days  or  hours  in 
acute  cases. 

By  giving  something  for  the  relief  of  indigestion  in  the  chronic  case, 
without  a  physical  examination  demonstrating  the  presence  of  a  gastric  or 
duodenal  ulcer  or  gallstones,  the  physician  may  be  responsible  for  the  peri- 
tonitis which  may  occur  weeks  or  months  later  as  a  result  of  perforation. 
Quite  as  certainly,  by  giving  a  cathartic  for  acute  indigestion  without  a 
physical  examination  in  a  case  of  gangrenous  appendicitis,  he  may  cause  a 
distribution  of  the  infectious  material  over  the  entire  peritoneal  cavity  by 
stimulating  peristalsis,  producing  a  diffuse  peritonitis.  This  in  turn  may 
destroy  the  life  of  the  patient  in  a  few  days.     For  a  fairly  trained  diag- 


GENERAL  SURGERY  OF  THE  ABDOMEN  281 

nostician  it  is  possible  to  recognize  all  of  these  conditions,  whether  they  be 
acute  or  chronic,  in  time  to  prevent  or  inhibit  peritonitis  if  he  makes  a  careful 
examination  when  the  patient  first  comes  under  his  care.  At  the  end  of 
this  chapter  a  number  of  conclusions  will  be  found,  which  contain  the  various 
elements  to  be  considered  in  planning  the  prevention  and  inhibition  of  peri- 
tonitis. 

At  this  point  the  part  played  in  the  production  and  acceleration  of  peri- 
tonitis by  the  use  of  cathartics  will  be  discussed  more  extensively.  Undoubt- 
edly, many  patients  lose  their  lives  from  general  peritonitis  because  they 
were  given  either  cathartics  or  food,  or  both,  by  mouth  after  the  beginning 
of  the  peritoneal  infection.  In  the  very  large  number  of  cases  which  have 
come  under  our  observation,  there  has  not  been  a  single  instance  of  death 
from  peritonitis  in  which  neither  cathartics  nor  food  had  been  given  by  mouth 
after  the  beginning  of  the  attack,  which  seems  to  be  a  most  important 
observation. 

The  introduction  of  cathartics  in  the  treatment  of  peritonitis.  Nearly 
forty  years  ago  the  phenomenal  success  in  abdominal  surgery  experienced 
by  Lawson  Tait  was  attributed  by  many  to  the  fact  that  he  administered 
cathartics  to  his  patients  directly  after  performing  laparotomies,  and  the 
fact  that  his  patients  regularly  recovered  without  sj'mptoms  of  peritonitis 
after  ordinary  abdominal  operations  performed  for  nonseptic  conditions,  while 
other  surgeons  lost  similar  patients  constantly  from  peritonitis  at  this  period, 
led  to  the  conclusion  that  cathartics  prevent  peritonitis.  He  says,  in  the 
Hastings  essay  for  1873,  ' '  The  administration  of  laxatives  within  a  few  hours 
after  the  operation  is  becoming  quite  a  common  practice  with  me,  this  inno- 
vation, in  my  opinion,  being  possibly  conducive  in  some  measure  to  my 
increased  success." 

This  theory  that  cathartics  can  prevent  or  inhibit  peritonitis  appeared 
very  frequently  in  essays  and  in  text-books  during  the  following  quarter  of 
a  century,  although,  in  the  meantime,  every  surgeon  had  learned  the  fact 
that  the  absence  of  peritonitis  following  Tait's  operations  was  due  to  the 
circumstance  that  he  was  a  clean,  rapid  surgeon,  who  neither  infected  his 
patients  nor  unnecessarily  traumatized  the  peritoneum,  and  that  because 
neither  infection  nor  trauma  were  present,  the  cathartics  he  gave  were 
harmless. 

During  these  years  many  medical  books  and  articles  contained  statements 
similar  to  the  following  referring  to  the  treatment  of  acute  appendicitis.  It 
will  not  be  necessary  to  quote  from  more  than  one  of  the  best  authorities 
who  now  never  gives  either  cathartics  or  food  in  acute  infection  of  any 
portion  of  the  peritoneal  cavity  because,  during  this  period,  all  of  the  best 
authorities,  like  Deaver,  Murphy,  Minter,  Fowler,  ^Morris,  made  similar  state- 
ments in  their  books.  "The  bowel  must  be  kept  clean  from  irritating  fecal 
matter,  by  enemata  if  possible,  by  a  good  cathartic  if  necessary."  "Evidence 
is  not  wanting  of  successful  results  obtained  by  medical  treatment,  especially 
in  the  use  of  saline  purgatives." 

Only  patients  in  whom  the  infection  was  still  confined  to  the  appendix 
and  those  in  whom  the  infection  had  been  sufficiently  circumscribed  by  strong 
adhesions  to  make  dissemination  of  septic  material  impossible,  which,  accord- 
ing to  the  careful  studies  of  Staunton,  rarely  occurs  before  the  seventh  day, 
furnished  safe  cases  for  this  treatment. 

At  that  time  this  surgeon's  mortality  in  operations  for  appendicitis  was 
also  ten  per  cent.,  and  since  prohibiting  all  forms  of  food  and  cathartics 
by  mouth,  and  giving  normal  salt  solution  by  rectum,  his  mortality  has  been 
reduced  to  less  than  one-fourth  of  this  percentage  in  precisely  the  same  class 
of  cases. 


282  GENERAL  SURGERY  OF  THE  ABDOMEN 

Mode  of  action  of  cathartics.  In  cases  in  which  the  primary  infection 
comes  from  a  circumscribed  point  like  the  appendix,  or  a  leaking  pus  tube, 
or  a  nearly  perforated  gastric,  duodenal  or  typhoid  ulcer  with  slightly 
adherent  omentum  covering  the  point  of  danger,  the  conditions  are  fair  for 
obtaining  a  circumscribed  instead  of  a  diffuse  infection.  The  same  is  true 
in  a  gall  bladder  with  a  gangrenous  mucous  lining. 

In  case  of  the  appendix  and  the  Fallopian  tube,  the  cecum,  sigmoid  and 
the  omentum  are  likely  to  confine  the  infection  to  the  pelvic  portion  of  the 
abdominal  cavity.  In  all  of  the  other  instances  the  burden  of  the  work 
of  protection  falls  upon  the  omentum,  but  so  long  as  the  infection  is  in  one 
circumscribed  location,  the  entire  free  portion  of  the  omentum  can  and  will 
arrange  itself  about  this  point  and  will  prevent  the  infectious  material  from 
passing  on  to  other  portions  of  the  peritoneum.  All  of  the  physiological 
forces  become  active  to  prevent  the  escape  of  this  septic  material  to  other 
portions  of  the  peritoneal  cavity.  The  colon  becomes  filled  with  gas  and 
acts  as  a  cofferdam.  The  small  intestines,  if  not  disturbed  by  cathartics  or 
food,  form  an  embankment  about  the  diseased  area. 

These  conditions  have  been  observed  innumerable  times  by  surgeons  who 
have  operated  in  acute  cases. 

The  nausea  prevents  the  patient  from  taking  food  unless  this  is  forced 
upon  him  by  some  foolish  friend  or  unless  it  is  prescribed  by  some  incompetent 
physician. 

The  abdominal  walls  become  rigid  and  form  an  anterior  splint.  Every- 
thing is  as  favorable  as  can  be  for  the  process  of  repair,  which  consists  in 
the  concentration  of  the  activity  of  millions  of  leucocytes  in  the  infected  area 
and  the  production  of  antibodies  in  the  blood  and  the  limitation  of  nutrition 
of  the  septic  micro-organisms  to  an  area  in  which  they  will  soon  become 
reduced  in  virulence. 

It  is  true  that  the  alimentary  canal  may  contain  septic  material,  but  this 
will  soon  be  excreted  through  the  stomach  and  can  be  readily  removed  by 
the  use  of  gastric  lavage.  If  no  further  food  of  any  kind  is  given  by  mouth, 
the  small  intestines  will  soon  be  free  from  septic  material,  and  gastric  lavage 
applied  once  or  twice  will  usually  suffice  to  remove  the  septic  material 
excreted  into  the  stomach,  although  in  rare  instances  it  is  necessary  to  repeat 
this  lavage  several  times  a  day  for  several  days. 

Were  .one  to  continue  placing  food  in  the  stomach  during  the  progress 
of  the  disease,  then  there  might  be  some  doubt  as  to  the  choice  between  the 
two  evils  of  leaving  a  quantity  of  decomposing  substance  in  the  alimentary 
canal  to  poison  the  patient,  or  forcing  it  out  by  means  of  a  cathartic  and 
incidentalh^  killing  the  patient  by  carrying  the  septic  material  from  this 
circumscribed  area  to  the  other  peritoneal  surfaces  by  the  peristalsis  caused 
by  the  cathartic. 

Since  it  is  possible  to  supply  the  necessary  amount  of  nourishment  by 
rectal  alimentation  and  a  sufficient  amount  of  fluid  by  the  continuous  normal 
salt  solution  introduced  by  the  drop  method  into  the  rectum,  or  by  any  one 
of  the  numerous  methods  which  have  been  described  by  others,  there  is  no 
reason  why  one  should  risk  harm  by  introducing  food  or  cathartics  by  mouth. 
No  good  can  come  from  it  because  it  is  not  needed.  That  harm  does  come 
from  it  is  not  only  plain  from  the  theoretical  reasons,  but  has  been  demon- 
strated in  a  large  number  of  cases. 

This  applies  to  all  cases  without  regard  to  the  form  of  surgical  treatment 
that  may  be  chosen  in  any  given  individual. 

Whatever  surgical  treatment  may  be  contemplated  in  case  of  any  form 
of  existing  peritonitis,  the  results  must  be  better  if  the  infection  is  not  diffused 
by  peristalsis.     There   can,   therefore,  be  no   reason  why  peristalsis  should 


GENERAL  SURGERY  OF  THE  ABDOMEN  283 

be  initiated  by  the  use  of  cathartics.    Even  the  smallest  amount  of  cathartic 
may  change  a  harmless  circumscribed  infection  into  a  serious  diffuse  peritonitis. 

One  demonstrable  change  consists  in  the  rapid  increase  in  leucocytosis 
even  after  the  administration  of  a  small  amount  of  cathartics.  One-tenth 
grain  of  calomel  with  one  grain  of  soda  may  increase  leucocytosis  several 
thousand  within  a  few  hours,  and  the  same  is  true  of  other  cathartics  and 
also  of  enemata,  except  when  given  by  the  drop  method.  "We  have  had  an 
opportunity  to  observe  this  in  a  hospital  whose  beds  are  open  to  the  general 
practitioners  of  the  community  in  which  it  is  located.  Some  of  these  practi- 
tioners give  cathartics  habitually  as  a  form  of  initiative  treatment  while  they 
are  trying  to  think  what  form  of  treatment  is  indicated.  This  has  given  us 
an  opportunity  to  study  the  effects  of  cathartics  upon  the  leucocytosis  in 
these  cases. 

A  former  assistant,  Dr.  John  L.  Yates,  has  proven  conclusively,  by  a  large 
series  of  experiments  upon  animals,  that  infectious  material  is  rapidly  diffused 
by  the  administration  of  food  or  cathartics,  because  of  the  establishment  of 
peristalsis.  Injecting  lampblack  into  the  abdominal  cavity,  he  found  that 
this  remained  in  a  circumscribed  location  so  long  as  the  intestines  were  at 
rest;  but  upon  the  administration  of  cathartics  it  is  rapidly  diffused  over  the 
entire  peritoneal  cavity.  The  same  was  true  of  septic  material  introduced 
in  the  same  manner. 

Constipation  is  looked  upon  rightly  as  a  cause  of  ill  health ;  consequently 
it  is  but  natural  that,  counting  upon  the  law  of  probabilities,  a  physician 
or  a  layman  who  gives  a  cathartic  in  every  case,  with  or  without  having 
previously  made  a  diagnosis,  will  have  fair  results  in  most  patients  who 
are  not  suffering  from  peritonitis.  Moreover,  in  cases  in  which  there  is  not 
as  yet  a  circumscribed  peritonitis,  especially  in  catarrhal  appendicitis,  the 
patient  feels  better  after  the  use  of  a  cathartic  and,  as  there  is  no  septic 
material  present  to  be  diffused  throughout  the  peritoneal  cavity,  no  harm 
can  come  to  this  class  of  patients. 

If  one  can  be  absolutely  certain,  therefore,  in  any  given  case,  that  there 
is  no  circumscribed  infection,  a  cathartic  can,  of  course,  be  given  safely  in 
that  case.  If  no  harm  comes  from  it,  the  diagnosis  has  been  confirmed,  but 
whenever  there  is  the  slightest  doubt  it  would  be  foolish  to  take  such  a  risk 
for  the  sake  of  confirming  a  diagnosis.  As  a  general  rule  it  may  be  stated 
that  in  all  doubtful  cases,  even  if  the  doubt  be  ever  so,  slight,  a  cathartic 
should  never  be  given  because  in  the  given  case  in  which  it  is  harmless  it 
is  not  needed,  as  the  bowels  will  be  spontaneously  evacuated,  and  in  the  other 
cases  cathartics  are  contraindicated. 

That  a  cathartic  is  safe  in  only  a  very  small  percentage  of  cases  was  proven 
by  Murphy's  statistics  of  1895,  which  showed  that  in  94  per  cent,  of  cases 
of  acute  appendicitis  pus  was  found  outside  the  appendix  at  the  time  they 
came  under  treatment.  It  is  plain  that  the  6  per  cent,  in  whom  the  infection 
is  still  confined  to  the  appendix  w411  all  recover  under  proper  surgical  treat- 
ment, and  the  94  per  cent,  in  whom  the  infection  is  already  beyond  the  tissues 
of  the  appendix  must  be  exposed  to  great  risk  if  peristalsis  is  caused  by  the 
administration  of  cathartics. 

Effect  of  cathartics  in  cases  of  mechanical  obstruction  of  the  intestine. 
However  harmful  it  may  be  to  administer  cathartics  in  cases  suffering  from 
circumscribed  peritonitis,  it  is  still  more  harmful  to  administer  these  remedies 
in  cases  suffering  from  mechanical  obstruction  of  the  intestines,  no  matter 
whether  this  be  due  to  strangulated  hernia,  volvulus,  Meckel's  diverticulum, 
constricting  bands  of  adhesion,  intussusception,  kinking  of  the  intestines, 
impacted  gallstone,  impacted  submucous  lipoma  or  fibroma  in  the  intestinal 


284  GENERAL  SURGERY  OF  THE  ABDOMEN 

wall  or  obstruction  due  to  malignant  growths  in  the  intestinal  wall  or  pressing 
upon  it  from  the  outside. 

In  every  ease  in  which  there  is  even  a  suspicion  of  mechanical  obstruc- 
tion of  the  bowel,  gastric  lavage  should  be  instituted  at  once  and  absolutely 
nothing  should  be  given  by  mouth. 

The  intestine  above  the  point  of  obstruction  suffers  so  severely  as  a  result 
of  the  pressure  from  the  peristaltic  action  caused  by  cathartics  that  the  walls 
become  permeable  to  the  passage  of  septic  material,  which  is  proven  by  the 
presence  of  micro-organisms  in  the  peritoneal  fluid,  and  the  mortality  is  at 
least  four  times  greater  in  cases  that  have  received  cathartics  than  in  those 
that  have  received  none.  In  many  cases  the  intestine  may  even  be  perforated 
above  the  constriction  as  a  result  of  the  use  of  cathartics.  All  of  these 
conditions  we  have  encountered  many  times  in  practice. 

Puerperal  sepsis  and  post-operative  sepsis  must,  of  course,  be  eliminated 
by  proper  prophylaxis. 

Although  convinced  that  abstaining  from  the  use  of  cathartics  alone  in 
cases  of  incipient  peritonitis  is  the  most  important  means  of  inhibiting  this 
disease,  still  we  believe  that  it  is  most  important  to  bear  in  mind  all  of  the 
following  conclusions  and  that,  when  these  have  been  thoroughly  applied 
in  practice,  deaths  from  peritonitis  will  be  almost  entirely  eliminated.  These 
conclusions  are  quite  as  applicable  to  cases  which  are  treated  surgically  as 
those  treated  without  surgical  intervention. 

It  would  be  most  unfortunate  if,  by  directing  attention  particularly  to 
the  harmful  effects  of  cathartics  in  peritonitis,  this  section  should  lead  espe- 
cially the  general  practitioner  to  think  that  this  is  the  only  dangerous  form 
of  treatment,  because  the  errors  pointed  out  in  the  following  conclusions  have 
also  destroyed  an  enormous  number  of  human  lives,  and  by  constantly  keeping 
them  in  mind  any  general  practitioner  can  reduce  his  mortality  decidedly. 

Conclusions.  1.  A  careful  physical  examination  should  always  be  made  in 
patients  suffering  from  gastric  disturbances,  nausea,  vomiting,  gaseous  dis- 
tension or  pain  in  any  portion  of  the  abdomen,  so  that  an  early  diagnosis  can  be 
made.  In  acute  cases  violent  manipulations  are  dangerous  and  not  necessary 
during  examination.     They  may  cause  a  diffusion  of  septic  material. 

2.  A  diagnosis  of  chronic  appendicitis,  gastric  or  duodenal  ulcer  or  gall- 
stones should  be  made  through  a  careful  study  of  the  history  and  physical 
exa-mination,  and  relieved  by  proper  treatment  before  a  perforation  is  possible. 

3.  Patients  suffering  from  intestinal  obstruction,  whether  this  be  due 
to  strangulated  hernia,  constriction  by  bands  or  adhesions,  volvulus,  intus- 
susception or  kinking  of  intestines,  Meckel's  diverticulum,  gallstones  or 
carcinoma,  should  be  operated  at  once  and  they  should  never,  under  a,ny 
circumstances,  receive  either  cathartics  or  food  by  mouth  after  this  condition 
is  even"  suspected, 

4.  Gastric  lavage  should  be  employed  in  these  cases  at  once  and  again 
immediately  before  operation,  and  it  is  well  to  leave  the  stomach  tube,  pref- 
erably the  form  invented  by  Kausch,  in  the  stomach  to  drain  out  any  intestinal 
fluid  which  may  regurgitate  during  the  operation.  Many  of  these  cases  can 
be  operated  under  local  anesthesia. 

5.  Opium  in  any  form  should  never  be  given  before  a  diagnosis  has  been 
made,  and  never  in  the  presence  of  any  form  of  peritonitis,  unless  gastric 
lavage  has  been  done,  and  the  introduction  of  every  form  of  nourishment 
and  cathartics  by  mouth  is  absolutely  prohibited.  This  applies  to  even  the 
simplest  forms  of  liquids,  like  beef  tea  or  broth,  and  also  to  the  use  of 
champagne  and  other  stimulants. 

6.  This  applies  quite  to  the  same  extent  to  post-operative  treatment. 


GENERAL  SUEGERY  OF  THE  ABDOMEN  285 

7.  In  military  surgery  it  is  most  important  as  a  prophylactic  measure 
that  soldiers  enter  the  firing  line  with  empty  stomachs  and  intestines. 

8.  Abdominal  wounds  made  during  battle,  with  large  objects  like  splinters 
from  shells,  indicate  immediate  operation. 

9.  Abdominal  wounds  inflicted  in  battle  by  small  calibre  bullets,  in  the 
absence  of  hemorrhage,  should  be  treated  by  absolute  rest;  not  even  water 
should  be  given  by  mouth. 

10.  An  exception  should  be  made  in  cases  which  can  be  in  the  hands  of 
the  operating  surgeon  with  satisfactory  assistants  and  facilities  within  two 
hours  after  the  injury.  Under  these  conditions  an  immediate  abdominal 
section  is  indicated. 

11.  Gastric  lavage  should  be  done  at  once  in  every  patient  suffering 
from  any  form  of  peritonitis,  except  from  stomach  or  duodenal  perforation, 
if  nausea  or  vomiting  or  gaseous  distension  is  present,  no  matter  what  other 
form  of  treatment  may  be  contemplated. 

12.  No  food  of  any  kind  whatever  and  no  cathartics  should  ever  be 
given  by  mouth  in  the  presence  of  peritonitis,  no  matter  what  other  form 
of  treatment  may  be  contemplated. 

13.  Even  water  by  mouth  should  be  prohibited  until  the  patient  is  well 
on  the  way  to  recovery. 

14.  Instillation  of  normal  salt  solution  by  the  drop  method,  by  rectum, 
as  introduced  by  Murphy,  or  by  some  other  safe  non-irritating  method,  is 
one  of  the  most  valuable  means  of  inhibiting  peritonitis.  It  is  well  to  give 
normal  salt  solution  continuously  from  one  to  two  hours  and  then  to  inter- 
rupt this  treatment  for  two  hours. 

15.  In  rare  cases  in  which  this  method  cannot  be  employed,  normal  salt 
solution  should  be  given  subcutaneously  in  quantities  of  500  to  1,000  ccm. 
sufficiently  often  to  overcome  thirst  and  keep  the  blood  vessels  filled. 

16.  Large  enemata,  except  by  the  drop  method,  should  never  be  given 
in  the  presence  of  peritonitis. 

17.  In  order  to  prevent  post-operative  peritonitis,  it  is  important  never 
to  traumatize  the  intra-abdominal  organs  unnecessarily  during  operation. 

18.  Much  less  handling  of  the  intestines  is  necessary  if  these  are  not 
distended  with  gas,  a  condition  which  can  best  be  secured  by  giving  the 
patient  two  ounces  of  castor  oil  on  the  day  before  the  operation,  but  this 
should  never  be  given  in  the  presence  of  even  the  slightest  amount  of  peri- 
tonitis in  any  form. 

19.  Gastric  lavage  following  abdominal  section  often  prevents  incipient 
peritonitis  from  progressing  by  inhibiting  peristalsis ;  it  should  always  be 
employed  in  the  presence  of  nausea  or  vomiting  or  gaseous  distension.  In 
order  to  prevent  gagging,  it  is  well  to  spray  the  pharynx  thoroughly  with 
a  2  per  cent,  solution  of  cocaine  ten  minutes  before  the  stomach  tube  is 
introduced. 

20.  In  acute  appendicitis  the  appendix  should  be  removed  before  the 
infection  has  extended  beyond  the  organ.  If  conclusion  No.  1  is  adhered 
to,  this  can  be  done  in  almost  every  case  with  almost  perfect  safety,  because 
the  patient  can  then  be  placed  in  the  hands  of  a  competent  surgeon  within 
thirty-six  or  forty-eight  hours  from  the  beginning  of  the  attack. 

21.  In  subacute  and  chronic  appendicitis  the  appendix  should  be  removed 
before  it  has  an  opportunity  to  cause  an  acute  attack. 

22.  In  acute  appendicitis  which  has  been  carried  through  an  attack  with- 
out an  operation,  it  is  well  to  confine  the  patient  absolutely  to  a  liquid  diet 
until  his  appendix  has  been  removed. 

23.  In  cases  of  acute  appendicitis,  either  perforative  or  gangrenous,  which 
have  received  some  form  of  food  or  cathartics  after  the  beginning  of  the 


286  GENERAL  SURGERY  OF  THE  ABDOMEN 

attack,  which  reach  the  care  of  a  surgeon  too  late  for  a  safe  early  operation 
and  are  suffering  from  beginning  diffuse  peritonitis,  gastric  lavage,  absolute 
abstinence  from  food  and  cathartics  by  mouth  and  the  slow  instillation  of 
normal  salt  solution  by  rectum  are  indicated. 

24.  This  will  result  in  the  increase  of  resistance  against  infection  to  such 
an  extent  that  97  per  cent,  of  these  cases  of  perforative  or  gangrenous  appen- 
dicitis can  later  be  operated  with  safety. 

25.  Feeding  should  be  entirely  by  enemata,  preferably  consisting  of  one 
ounce  of  a  commercial  concentrated  liquid  food  dissolved  in  three  ounces  of 
normal  salt  solution  given  slowly  every  three  or  four  hours  through  a  small 
rubber  catheter  introduced  into  the  rectum  not  more  than  three  inches. 

26.  From  ten  to  thirty  drops  of  deodorized  tincture  of  opium  should  be 
added  to  each  rectal  feeding,  until  there  is  no  longer  any  pain. 

27.  Placing  these  patients  in  the  Fowler  position  greatly  increases  their 
safety. 

28.  The  application  to  the  abdomen  of  a  large,  hot,  moist  dressing  of 
equal  parts  of  a  saturated  solution  of  boric  acid  and  alcohol  greatly  increases 
the  comfort  of  these  patients  and  prevents  harm  from  manipulations. 

29.  It  is  important  for  the  general  practitioner  and  the  general  public 
to  become  familiar  with  the  danger  of  giving  any  kind  of  nourishment  or 
cathartics  by  mouth  in  the  presence  of  impending  peritonitis  from  any  cause, 
and  that  this  applies  to  milk,  broth  and  other  forms  of  liquids  and  even 
to  water. 

The  repetitions  in  these  conclusions  are  intentional  because  it  has  seemed 
wo'rth  while  to  cover  every  possible  point  so  completely  that  no  one  taking 
the  time  to  read  these  conclusions  carefully  could  be  in  doubt.  As  stated 
'  before,  these  conclusions  are  all  based  upon  the  observation  of  a  very  large 
number  of  cases  and  they  are  not  in  any  way  theoretical,  as  they  all  have  an 
intensely  practical  foundation. 

TUBERCULOUS  PERITONITIS 

Typical  case.  The  patient  is  a  married  women  thirty-two  years  of  age,  giving  the  follow- 
ing history : 

Her  father  died  of  pulmonary  tuberculosis  at  the  age  of  fifty.  One  sister  died  from  the 
same  cause  at  the  age  of  thirty.  Another  sister  is  suifering  from  the  same  desease  at  the 
present  time.  The  patient  had  measles  as  a  child  but  otherwise  has  had  good  health.  Her 
menstruation  began  at  the  age  of  fifteen  and  was  regular  but  somewhat  painful.  She  married 
at  twenty-two;  has  had  five  normal  pregnancies.  She  has  suffered  from  constipation  during 
the  past  ten  years.  The  abdomen  has  been  distended  for  several  years  and  she  has  suffered 
from  eructations  of  gas.  About  four  months  ago  fluid  was  first  discovered  in  the  abdominal 
cavity.  She  was  then  put  to  bed  and  received  internal  treatment,  but  the  accumulation  of  fluid 
in  the  peritoneal  cavity  has  constantly  increased.  In  the  meantime  she  has  lost  ten  pounds 
in  weight.  She  has  occasional  pains  in  the  left  side  of  the  abdomen,  lasting  a  few  hours 
at  a  time.  The  abdomen  is  enlarged  to  the  size  of  a  six  months'  pregnancy,  but  is  flattened 
and  there  is  a  prominence  of  the  umbilicus. 

The  patient  is  sufficiently  nourished;  her  tongue  is  clean;  the  appetite  fair;  bowels  con- 
stipated; heart,  lungs,  liver  and  kidneys  normal;  her  temperature  is  normal;  pulse  is  80, 
regular  and  fairly  strong;  abdomen  is  distended  and  tympanitic  above.  A  hard  mass  is  felt 
in  the  right  side  "of  the  abdomen  opposite,  and  a  little  below,  the  umbilicus;  slightly  movable, 
but  does  not  move  with  respirations.  Her  right  kidney  is  movable.  There  is  dullness  upon 
percussion,  with  the  exception  of  a  small  area  over  the  most  prominent  part  of  the  abdomen. 
The  area  of  dullness  changes  with  a  change  in  her  position.  Upon  vaginal  examination  the 
uterus  is  found  bound  down  by  a  solid  mass  in  the  pelvis. 

This  history,  together  with  the  physical  examination,  would  indicate  the 
presence  of  a  tuberculous  peritonitis  with  fluid  in  the  free  peritoneal  cavity. 
The  fact  that  the  heart,  liver  and  kidneys  are  normal  would  indicate  that  the 
fluid  contained  in  the  peritoneal  cavity  must  be  the  result  of  a  local  irritation. 


GENERAL  SURGERY  OF  THE  ABDOMEN  287 

This  might  be  due  to  the  presence  of  a  papilloma  originating  from  the  ovary, 
but  that  would  scarcely  account  for  the  mass  in  the  upper  portion  of  the 
peritoneal  cavity,  which  is  probably  the  result  of  adhesions  between  the 
omentum  and  the  intestines,  due  to  abdominal  peritonitis.  It  is  not  difficult 
in  this  case  to  differentiate  between  this  condition  and  the  presence  of  an 
ovarian  cyst,  because  the  abdominal  cavity  is  not  so  thoroughly  distended  as 
to  make  all  portions  dull  upon  percussion,  nor  are  the  small  intestines  so 
completely  agglutinated  bj^  tuberculous  peritonitis  as  to  be  held  away  from 
the  circumscribed  accumulation  of  ascitic  fluid,  making  a  resonant  area  above 
or  to  the  side.  The  tubercular  family  history  would  make  a  tubercular  infec- 
tion especially  likely,  although  many  of  these  cases  obtain  their  infection 
from  food.  Most  of  these  patients  have  at  least  a  little  elevation  of  tempera- 
ture in  the  afternoon  or  evening,  or  a  subnormal  temperature  in  the  morning, 
and  if  careful  record  of  this  patient's  temperature  had  been  taken  throughout 
her  period  of  sickness,  we  are  confident  that  this  condition  would  have  been 
found  at  some  time.  Even  at  the  present  such  a  variation  in  temperature 
could  undoubtedly  be  established  within  a  week  or  two  by  taking  the  tem- 
perature regularly. 

The  diagnosis  can  be  confirmed  by  using  the  tuberculin  test  or  bj'^  applying 
the  test  introduced  by  Von  Pirquet,  but  in  cases  as  clear  as  this  one  these 
additional  tests  are  not  necessary.  The  latter  is  absolutely  harmless,  hence 
there  is  no  reason  why  it  should  not  be  used  in  every  instance.  The  tuberculin 
test  when  cautiously  applied  so  rarely  does  harm  that  in  the  event  of  doubt, 
it  is  always  well  to  employ  it,  as  it  is  somewhat  more  reliable  than  the  other. 

Treatment.  This  patient  has  been  under  constant  treatment  during  the 
past  four  months  by  a  careful  and  competent  physician.  The  treatment  con- 
sisted of  hygienic  measures,  of  rest  in  bed,  of  intestinal  antiseptics,  and  she 
has  been  given  good,  wholesome  food,  care  being  exercised  that  the  milk,  and 
all  the  other  food  which  might  possibly  contain  tubercle  bacilli,  was  carefully 
sterilized  before  use. 

An  incision  three  inches  in  length  is  made  in  the  linea  alba  below  the 
umbilicus.  This  at  once  permits  a  large  quantity  of  thin,  slightlj^'-yellowish 
fluid  to  escape,  leaving  the  peritoneal  cavity  studded  with  tubercles  through- 
out, the  intestines  and  omentum  being  somcAvhat  adherent  in  the  upper  por- 
tion of  the  peritoneal  cavity;  the  cecum  and  appendix  to  the  right  being 
covered  with  the  same  small  tubercles,  the  uterus,  ovaries  and  tubes,  and  the 
sigmoid  flexure,  forming  a  mass  in  the  pelvis  also  covered  with  tubercles.  The 
peritoneum  is  one-eighth  of  an  inch  in  thickness,  somewhat  purplish  in  color 
and  completely  studded  with  tubercles. 

After  carefully  sponging  away  all  of  the  free  fluid  with  moist  aseptic  gauze 
pads,  exercising  great  care  not  to  cause  any  abrasions  by  the  manipulations,  a 
large  glass  drainage  tube  covered  with  four  thicknesses  of  formidin  gauze  is 
placed  in  the  cul  de  sac  and  permitted  to  project  through  the  lower  angle 
of  the  wound,  then  the  abdominal  wound  is  closed. 

It  is  doubtful  whether  in  a  patient  like  this  it  is  better  to  close  the 
abdominal  cavity  at  once  or  to  insert  a  drainage  tube  surrounded  with  iodoform 
gauze,  as  previously  described.  In  case  the  latter  method  is  chosen  the  tube 
and  gauze  should  be  removed  as  soon  as  the  drainage  has  ceased. 

In  following  the  experience  of  a  number  of  surgeons  who  invariably  drain 
these  cases,  and  others  who  close  the  abdominal  cavity  without  drainage,  it 
has  seemed  that  the  former  have  much  fewer  recurrences  than  the  latter. 
This  has  also  been  our  personal  experience,  so  that  we  now  drain  invariably 
in  all  cases  in  which  we  operate  for  the  relief  of  tuberculous  peritonitis. 

Medical  vs.  surgical  treatment.  At  the  present  moment  the  treatment  of 
tubercular  peritonitis  seems  to  drift  back  into  the  hands  of  the  practitioner 


288  GENERAL  SURGERY  OF  THE  ABDOMEN 

of  internal  medicine,  after  having  been  virtually  considered  a  surgical  disease. 
Until  very  recently,  and  for  a  period  of  more  than  ten  years,  siirgeons  were 
generally  willing  to  undertake  the  surgical  treatment,  and  their  immediate 
results  were  usually  so  favorable  that  it  seemed  as  though  the  surgical  treat- 
ment had  become  permanently  established.  Recent  literature,  however,  indi- 
cates that  surgeons  with  a  considerable  experience  report  approximately  fifty 
per  cent,  of  recoveries  extending  over  at  least  two  years.  Those  who  report 
fewer  cases  show  a  larger  percentage  of  recoveries,  but  it  is  scarcely  fair  to 
count  these  cases,  because  it  is  likely  that  in  this  group  a  greater  proportion 
of  favorable  than  unfavorable  instances  are  reported,  i.  e.,  of  all  surgeons  who 
have  operated  upon  only  one  or  two  of  these  cases  those  who  have  been  for- 
tunate in  their  results  will  feel  inclined  to  encourage  others,  while  those  who 
have  been  unfortunate  abandon  the  subject  as  unworthy  of  special  attention. 
Drainage,  irrigation  and  medication  of  the  abdominal  cavity  are  not  only 
considered  useless  by  many  writers  of  great  experience,  but  actually  unde- 
sirable, and  the  simpler  the  operation  performed  the  better  will  be  the  result 
according  to  these  authorities.  This  idea  is  illustrated  in  many  of  the  instances 
that  were  found  to  suffer  from  tubercular  peritonitis  when  the  operation  had 
been  performed  with  the  expectation  of  removing  an  ovarian  cyst,  the  fluid 
drained  and  the  abdominal  wound  either  drained  or  closed.  In  many  such 
cases  the  condition  appeared  absolutely  hopeless  and  it  seemed  to  be  foolish 
to  do  anything  at  all. 

A  very  large  number  of  similar  cases  have  been  reported  by  different 
authors  and  the  literature  contains  many  interesting  compilations  of  cases 
which  appear  to  show  great  benefit  from  abdominal  section.  During  the  past 
few  years  it  has  been  shown  that  the  results  in  cases  treated  for  tubercular 
peritonitis  in  the  medical  departments  of  many  of  the  great  hospitals  were 
about  the  same  as  those  in  the  surgical  clinics.  If  these  observations  are  cor- 
rect it  would  appear  as  though  these  patients  should  be  placed  under  medical 
rather  than  surgical  treatment,  because  the  latter  is,  of  course,  connected  with 
a  greater  amount  of  pain  and  a  slight  amount  of  danger  from  the  operation 
itself.  That  many  cases  have  recovered  permanently  and  completely  after 
abdominal  section  there  can  be  no  doubt,  because  this  has  been  positively 
proven  by  autopsies  upon  patients  who  died  from  other  causes,  when  they 
were  found  completely  cured,  tuberculosis  having  been  demonstrated  at  the 
operation  and  the  diagnosis  confirmed  microscopically. 

Many  of  these  patients  have  later  been  operated  for  other  conditions  and 
the  peritoneum  has  been  found  so  entirely  free  from  evidences  of  tuberculosis 
that  it  seemed  impossible  to  imagine  it  to  be  the  same  peritoneum.  We  have 
made  this  observation  in  a  number  of  our  own  patients. 

Although  the  diagnosis  cannot  be  made  so  positively  in  those  treated 
without  operation,  it  seems  clear  that  many  undoubted  cases  have  been  cured 
by  medical  and  hygienic  measures.  Since  the  introduction  of  the  tuberculin 
and  Von  Pirquet's  tests  a  positive  diagnosis  can  be  made  even  in  cases  not 
operated,  hence  statistics  in  the  future  will,  of  course,  be  more  acceptable. 

An  analysis  of  the  various  papers  on  both  sides  of 'this  controversy  shows, 
it  seems,  that  the  authors  were  not  discussing  the  same  class  of  patients. 

Medical  treatment  generally  instituted  early.  The  medical  practitioners 
seem  to  deal  with  these  cases  earlier  in  the  attack,  while  the  condition  is  still 
more  or  less  acute ;  on  the  other  hand,  surgeons  meet  with  the  cases  in  the 
chronic  condition  after  those  which  are  curable  by  medical  treatment  have 
been  eliminated.  In  other  words,  the  medical  treatment  is  virtually  applied 
to  all  cases  at  first,  and  if  persisted  in  will  result  in  approximately  fifty  per 
cent,  of  cures,  of  which  about  one-half  have  a  recurrence  after  a  number  of 
years.    If  the  medical  treatment  in  the  remaining  fifty  per  cent,  of  cases  is 


GENERAL  SUEGERY  OF  THE  ABDOMEN  289 

continued  after  the  time  when  it  becomes  apparent  that  it  has  no  beneficial 
effect,  then  the  chances  are  that  such  cases  will  go  from  bad  to  worse  until 
they  succumb.  If,  however,  surgical  treatment  is  employed  in  these  cases  in 
which  medical  treatment  has  proven  to  be  of  no  benefit,  then  all  of  the  cases 
of  this  group  which  recover  permanently,  as  well  as  those  which  are  tem- 
porarily improved,  constitute  an  absolute  gain,  because  they  reduce  the  failures 
from  the  internal  treatment  and  increase  the  favorable  results  by  their  entire 
number. 

It  is  interesting  to  note  that  all  authors  who  favor  the  medical  treatment 
of  these  cases  insist  upon  beginning  during  the  early  part  of  the  attack,  in 
fact,  as  soon  as  the  diagnosis  has  been  made.  They  all  advise  primarily 
hygienic  measures ;  rest  in  bed,  intestinal  antiseptics,  some  form  of  creosote, 
and  some  form  of  iodine  to  be  given  internally;  also  sterilized,  concentrated 
food  and  living  and  sleeping  in  the  open  air. 

Many  external  applications  have  been  advised,  especially  ointments  con- 
taining some  form  of  iodine  or  mercury.  Those  advising  surgical  treatment 
combine  hygienic  treatment  with  it  and  advise  that  this  be  continued  indefi- 
nitely after  the  recovery  from  the  operation. 

Of  those  who  advise  operative  treatment  several  surgeons  of  large  experi- 
ence caution  against  operation  too  early  in  the  attack,  because  recurrence  is 
more  likely  in  case  the  operation  is  performed  before  the  tubercles  are  fully 
developed.  It  has  been  demonstrated  experimentally  that  this  is  a  wise  pre- 
caution to  take,  because  new  tubercles  developed  in  animals  after  an  early 
laparotomy,  while  in  other  similar  animals  a  later  operation  has  resulted  in 
a  permanent  cure.  The  cure  is  attributed  to  the  secretion  of  an  antitoxin 
which,  it  is  claimed,  is  not  produced  before  the  tubercles  have  been  fully 
developed. 

Many  experiments  have  been  made  to  determine  the  manner  in  which  the 
cure  is  accomplished.  It  has  been  demonstrated  in  animals,  upon  which  an 
artificial  tubercular  peritonitis  had  been  produced,  that  the  abdominal  section 
is  followed  by  a  severe  hyperemia  which  lasts  longer  than  in  cases  not  suffer- 
ing from  tubercular  peritonitis.  This  is  considered  the  curative  element  which 
is  attributed  to  the  action  of  the  air  upon  the  diseased  peritoneum,  as  it  does 
not  occur  when  the  animals  are  kept  submerged  in  normal  salt  solution  during 
the  operation.  Other  authors  have  attributed  the  curative  effect  of  abdominal 
section  to  an  antitoxin  produced  from  the  dead  bacilli,  which  will  be  absorbed. 
These  conclusions  are  also  based  upon  experimental  research.  It  has  been 
found  that  the  antitoxic  effect  of  the  ascitic  fluid  increases  with  its  age. 

Our  experience  in  the  treatment  of  tuberculous  peritonitis  in  patients  who 
belong  to  a  class  in  whom  dietetic,  hygienic,  and  medicinal  treatment  had 
been  carefully  carried  out  for  a  considerable  period  of  time  before  surgical 
intervention  was  determined  upon,  now  covers  a  very  large  number  of  cases. 
Many  of  these  we  have  followed  for  years  after  they  left  the  hospital.  In  the 
former  editions  of  this  book  we  tabulated  thirty-two  cases  operated  between 
1892  and  1902.  Space  does  not  permit  the  tabulation  of  all  of  the  cases  that 
we  have  operated  during  the  fifteen  years  which  have  passed  since  that  time, 
but  it  seems  proper  to  give  our  conclusions,  which  are  based  upon  a  study 
of  the  literature  which  has  appeared  since  that  time,  and  upon  our  personal 
experience. 

Conclusions.  1st.  Patients  suffering  from  tubercular  peritonitis  should 
first  be  subjected  to  careful  medical,  dietetic  and  hygienic  treatment. 

2nd.  This  treatment  should  consist  in  the  use  of  intestinal  antiseptics, 
anti-tubercular  remedies  and  rest  in  bed.  Sterilized  food  and  improved 
hygienic  conditions  generally  should  be  employed.  The  vaccine  treatment 
should  be  carefully  tried  in  these  cases.    X-ray  treatment  should  also  be  tried. 


290  GENERAL  SURGERY  OF  THE  ABDOMEN 

3rd.  So  long  as  the  patient's  condition  improves  reasonably  this  treat- 
ment should  be  continued. 

4th.  In  case  the  patient's  condition  does  not  improve,  or  becomes  worse, 
abdominal  section  is  indicated, 

5th.  If  the  disease  is  confined  to  a  part  which  can  be  safely  removed 
without  injuring  any  portion  of  the  tuberculous  peritoneum  this  should  be 
done,  provided  the  surface  can  be  covered  with  healthy  peritoneum. 

6th.  If  the  removal  of  any  infected  portion  necessitates  the  severing  of 
the  tuberculous  peritoneum  or  leaving  a  portion  of  the  peritoneal  surface 
denuded,  the  diseased  tissue  must  not  be  disturbed. 

7th.  In  case  there  is  fluid  in  the  peritoneal  cavity,  it  is  doubtful  whether 
it  is  best  to  remove  any  tuberculous  tissue,  even  though  it  be  circumscribed. 

8th.  Enormous  quantities  of  the  tuberculous  material  can  be  absorbed  from 
the  peritoneal  cavity  after  simple  laparotomy. 

9th.  It  is  best  to  avoid  all  manipulation  of  the  intra-abdominal  organs 
during  the  operation,  in  case  there  is  a  diffuse  tuberculous  infection,  and  to 
confine  the  operation  to  simply  opening  the  peritoneal  cavity,  permitting  the 
fluid  to  drain  out,  admitting  air  to  the  peritoneal  cavity,  draining  the  cavity 
with  a  glass  tube  covered  with  gauze  and  closing  the  abdominal  wound. 

10th.  Peritoneal  adhesions  should  never  be  disturbed  in  patients  suffering 
from  tubercular  peritonitis  with  ascites  for  fear  of  causing  intestinal  fistulas. 

11th.  During  the  time  of  recovery  from  the  surgical  operation,  and  for 
a  considerable  period  of  time  after  this,  the  patient  should  be  treated  medically 
and  with  carefully  regulated  X-ray. 

12th.  The  hygienic  conditions  of  the  patient  must  be  permanently  im- 
proved and  he  must  not  be  permitted  to  expose  himself  to  the  influences  which 
primarily  caused  the  tuberculous  infection. 

13th.  Permanency  of  cure  is  much  more  likely  in  patients  who  are  not 
predisposed  to  pulmonary  tuberculosis. 

14th.  Chronic  cases  with  fluid,  particularly  if  encapsulated,  and  not  bene- 
fited by  medical  and  hygienic  measures,  are  especially  amenable  to  surgical 
treatment. 

15th.    Repeated  operations  are  indicated  in  case  of  re-accumulation  of  fluid. 

16th.  It  is  important  to  regulate  the  hygiene  and  diet  of  these  patients 
permanentl}'  after  they  have  recovered  from  this  disease. 

17th.  It  is  especially  important  to  locate  the  source  of  the  primary  infec- 
tion and  to  make  reinfection  from  this  source  impossible. 

18th.  If  possible  they  should  change  their  residence  sufficiently  to  insure 
satisfactory  hygienic  conditions. 

19th.  All  milk  and  all  meats  should  be  sufficiently  cooked  to  prevent 
reinfection  from  these  sources. 

20th.  In  employing  the  vaccine  treatment  it  is  of  the  greatest  importance 
to  use  a  very  small  dosage,  a  good  rule  being  to  administer  one-half  of  the 
smallest  dose  that  will  cause  the  slightest  reaction. 

During  the  past  years  we  have  found  the  use  of  intensive  X-ray  treatment 
of  great  benefit  in  these  cases.  "We  have  given  an  intensive  X-ray  treatment 
over  the  location  of  the  peritonitis  each  day  for  six  successive  days,  then  we 
have  interrupted  this  for  some  three  to  four  weeks,  when  we  have  repeated 
the  treatment.  Even  after  the  first  treatment  there  is  usually  a  marked 
permanent  improvement,  which  is  increased  after  each  one  of  the  successive 
treatments  Of  course,  general  hygiene  and  diet,  out-of-door  sleeping,  and 
rest  in  bed  as  long  as  there  is  any  temperature,  must  be  continued  notwith- 
standing this  addition  to  our  plan  of  treatment. 


GENERAL  SURGERY  OF  THE  ABDOMEN         291 

GENERAL  CONSIDERATIONS  IN  BOWEL  SURGERY 

The  greatest  number  of  operations  upon  the  intestines  are  performed  for 
the  relief  of  mechanical  obstruction.  This  may  be  due  to  strangulation,  as  in 
strangulated  hernia,  or  constriction  due  to  a  cicatricial  band  or  an  adherent 
Meckel's  diverticulum,  or  an  adherent  appendix  or  a  volvulus.  Again  opera- 
tion may  be  needful  for  the  relief  of  obstruction  due  to  a  foreign  body  in 
the  alimentary  canal,  such  as  a  gall-stone  or  an  enterolith,  or  to  a  malignant 
growth  occluding  the  lumen  of  the  intestine  or  to  an  intussusception. 

General  principles  in  bowel  surgery.  There  are  a  few  general  principles 
which  should  be  borne  in  mind  in  all  surgical  work  upon  the  intestine,  viz. : 

1.  The  circulation  should  be  as  perfect  as  possible  at  the  point  of  opera- 
tion. There  is  alwaj^s  great  danger  of  interfering  with  the  blood  supply 
when  sutures  or  ligatures  are  applied  in  the  vicinity  of  the  omentum  or  the 
mesentery. 

2.  Care  should  be  taken  never  to  apply  stitches  or  ligatures  to  the  omen- 
tum near  its  attachment  to  the  colon,  because  this  is  frequently  followed 
by  gangrene. 

3.  In  all  operations  it  is  important  to  apply  the  sutures  so  that  the  two 
layers  of  the  mesentery  are  held  together,  because  the  space  between  these 
layers  is  not  covered  with  peritoneum  and  is  consequently  deprived  of  nutri- 
tion if  this  precaution  be  not  taken.  AVhen  an  end-to-end  anastomosis  is  made 
in  the  small  intestine  this  danger  can  be  still  further  guarded  against  by 
placing  the  ends  so  that  the  mesentery  does  not  come  directly  in  apposition 
in  the  two  segments,  twisting  one  segment  a  few  degrees  to  the  right  and  the 
other  a  few  degrees  to  the  left,  so  that  there  is  a  distance  of  about  one-eighth 
of  the  circumference  of  the  intestine  between  the  mesenteric  attachments  of 
the  two  segments. 

4.  The  same  principle  applies  to  the  choice  of  location  and  form  of  the 
anastomosis.  It  is  always  safer  to  make  an  anastomosis  where  it  is  possible 
to  unite  surfaces  which  are  covered  with  peritoneum,  hence  in  many  instances 
a  side-to-side,  or  an  end-to-side  anastomosis  is  to  be  preferred  to  an  end-to-end 
junction. 

5.  Tension  should  always  be  avoided. 

6.  The  omentum  can  be  utilized  to  enforce  an  anastomosis  by  supplying 
nutrition  from  its  rich  circulation. 

7.  AYhen  an  anastomosis  or  enterorrhaphy  is  performed  after  removing 
a  portion  of  gangrenous  intestine  the  proximal  segment  is  likely  to  cause 
leakage  unless  the  enterorrhaphy  is  made  a  considerable  distance  above  the 
portion  of  intestine  that  was  gangrenous. 

8.  In  case  of  tumors  of  the  mesentery  it  is  wise  to  make  an  anastomosis 
which  will  permit  the  passage  of  intestinal  contents  above  the  point  at  which 
the  nutrition  has  been  impaired  by  the  removal  of  a  mesenteric  tumor. 

9.  Care  must  be  taken  to  prevent  angulation,  which  will  result  later  in 
obstruction. 

10.  Allowance  must  be  made  for  shrinkage  of  the  anastomosis  openings, 
due  to  cicatricial  constriction. 

11.  Care  must  be  used  to  prevent  free  spaces  underneath  intestines  through 
which  hernige  may  occur  later. 

12.  Raw  surfaces  should  never  be  left  in  intestinal  operations  because 
adhesions  are  especially  bad  in  these  cases. 

EXCISION  OF  THE  CECUM 

Tjrpical  history.  The  patient  is  a  farmer  fifty-six  years  of  age  who  gives  the  following 
history:  Family  and  previous  history  negative.  Has  enjoyed  good  health  and  has  been 
able  to  work  hard  until  a  few  months  ago.     The  only  discomfort  he  has  experienced  has  been 


292  GENERAL  SURGERY  OF  THE  ABDOMEN 

from  chronic  constipation  whicli  has  existed  for  many  years,  but  which  has  alternated  during 
the  past  year  with  acute  attacks  of  "dysentery"  which  have  lasted  but  a  day  or  two  at  a 
time.  He  has  suffered  from  indigestion  and  from  gaseous  distension  of  the  abdomen.  The 
latter  condition  has  become  worse  constantly  during  the  past  few  months.  In  the  meantime 
the  patient  has  lost  forty  pounds  in  weight,  his  appetite  having  constantly  become  more  and 
more  impaired,  and  during  the  past  few  weeks  he  has  frequently  experienced  a  feeling  of 
nausea. 

He  is  a  somewhat  emaciated,  slightly  cachectic  man,  skin  dry,  very  slightly  jaundiced, 
tongue  coated,  appetite  poor,  severely  constipated,  heart,  lungs  and  kidneys  normal,  temper- 
ature slightly  sub-normal.  Abdomen  thin-walled,  soft,  slightly  distended,  peristalsis  of  small 
intestines  can  be  seen  on  surface  of  the  abdomen.  At  a  point  half-way  between  the  end  of 
the  twelfth  rib  and  the  anterior  superior  spine  of  the  ilium  a  hard,  oval,  slightly  lobulated 
mass  apparently  four  inches  in  length  and  two  inches  in  diameter  can  be  felt  through  the 
abdominal  wall.  It  is  slightly  movable  and  not  especially  painful  upon  manipulation.  It 
seems  to  be  attached  posteriorly.  Upon  inflation  of  the  colon  by  means  of  a  pump  attached 
to  a  rectal  tube  the  tumor  is  not  displaced  and  the  gas  does  not  distend  the  colon  in  front 
of  it.     The  distension  seems  to  extend  to  a  point  directly  above  the  beginning  of  the  tumor. 

Diagnosis.  A  careful  review  of  this  history  must  direct  our  attention 
to  the  existence  of  partial  obstruction  of  the  alimentary  canal,  which  is 
increasing  in  character  and  has  of  late  become  almost  complete,  as  indicated  by 
the  frequent  feeling  of  nausea. 

The  location  of  the  tumor  corresponds  to  the  cecum  or  the  ascending 
colon.  Its  sessile  nature  would  indicate  the  same  organ.  The  fact  that  it  is 
not  disturbed  by  the  inflation  of  the  colon  would  eliminate  the  kidney  and 
the  gall  bladder.  The  fact  that  continued  treatment  with  cathartics  does  not 
affect  the  size  or  form  of  this  tumor  would  eliminate  fecal  impaction.  The 
age  of  the  patient  and  the  cachexia  would  point  toward  malignancy.  We  will 
consequently  make  a  diagnosis  of  carcinoma  of  the  cecum  or  the  ascending 
colon,  or  both. 

Indications  for  treatment.  There  has  been  a  constant  increase  in  the 
obstruction,  hence  it  is  to  be  expected  that  a  complete  interference  must 
occur  soon.  In  order  to  avoid  this  some  radical  measure  must  be  instituted. 
Moreover,  this  should  be  undertaken  before  the  patient's  strength  has  declined 
still  more.  "We  shall  consequently  advise  an  operation  as  soon  as  the  patient 
has  received  the  necessary  preparation. 

Complete  intestinal  obstruction  might  occur  in  this  case  at  any  time  by 
the  occlusion  of  the  slight  remaining  opening  in  this  intestine  with  some 
small  mass  of  undigested  food.  A  small  piece  of  meat  fiber  or  an  orange 
seed,  and  in  a  number  of  cases  an  enterolith,  has  been  observed  to  cause  a 
complete  obstruction.  In  case  this  occurs  the  condition  becomes  exceedingly 
grave  at  once,  because  the  same  symptoms  will  arise  which  characterize 
acute  mechanical  obstruction  of  the  intestine,  namely,  pain,  sudden  gaseous 
distension  of  the  abdomen,  nausea,  vomiting  and  shock.  Patients  quite 
advanced  in  age  and  greatly  reduced  by  long-continued  disease  do  not  bear 
this  condition  well. 

The  question  of  an  immediate  operation.  The  question  consequently  arises 
as  to  the  advisability  of  an  immediate  operation  when  a  complete  obstruc- 
tion has  occurred.  Should  the  patient  come  under  treatment  at  once  the 
immediate  operation  is  undoubtedly  indicated,  because  the  intestines  are 
still  in  a  good  condition  and  the  patient  has  not  lost  much  strength.  It 
has,  however,  been  our  experience  that  these  patients  have  become  accus- 
tomed to  the  use  of  strong  cathartics  and  that  consequently  they  are  likely 
to  employ  such  means  for  several  days  before  consulting  a  physician,  chang- 
ing from  one  to  the  other  drug  until  they  are  completely  exhausted.  In 
such  examples  we  have  found  that  an  immediate  operation  is  usually  fol- 
lowed by  the  speedy  death  of  the  patient,  because  his  strength  has  been 
greatly  impaired  and  great  pressure  has  been  brought  to  bear  upon  the  badly 
nourished  intestinal  walls  above  the  point  of  obstruction  from  the  constant 


GENERAL  SURGERY  OF  THE  ABDOMEN  293 

use  of  strong  cathartics.  The  intestines  are  distended,  making  an  operation 
extremely  tedious.  This  distension  is  accompanied  by  a  greater  permeability 
of  the  walls  to  the  passage  of  micro-organisms,  hence  an  infection  is  favored 
in  this  manner.  It  usually  becomes  necessary  to  open  the  intestine  and  to 
permit  its  contents  to  escape  before  the  bowels  can  be  replaced  in  the  abdomi- 
nal cavity.  This  evacuation  should  be  accomplished  through  a  large  glass 
tube,  to  be  described  presently,  through  which  the  intestine  should  be  thor- 
oughly irrigated  with  normal  salt  solution  at  105°  to  110°  F,  The  adminis- 
tration of  cathartics  after  complete  obstruction  has  occurred  accounts  for 
the  extremely  high  death  rate  in  cases  operated  upon  under  these  conditions. 

For  a  number  of  years  we  have  consequently  followed  another  plan  and 
have  found  it  far  safer  for  the  patient.  Many  cases  brought  to  the  hospital 
in  an  apparently  hopeless  state  have  improved  from  day  to  day  and  were 
presently  carried  to  a  point  at  which  it  was  possible  to  perform  the  necessary 
operation  safely.  Of  course  there  are  cases  which  are  moribund  at  the  time 
of  admission  to  the  hospital  and  these  will  die,  usually  within  a  few  hours 
after  admission,  no  matter  whether  or  not  they  are  operated. 

Conservative  treatment.  The  treatment  that  has  been  followed  by  the 
greatest  percentage  of  recoveries  in  our  experience  has  consisted  in  reducing 
the  pressure,  as  much  as  possible,  above  the  point  of  constriction.  This  can 
be  accomplished  best  by  performing  gastric  lavage  several  times,  at  intervals 
of  a  few  hours,  under  cocain  anesthesia  of  the  pharynx.  There  is  usually 
a  regurgitation  of  decomposing  material  into  the  stomach,  which  will  be 
removed  by  the  gastric  lavage.  In  this  manner  the  stomach,  and  the  intes- 
tine above  the  obstruction,  soon  become  emptied  of  decomposing  material  and 
gas.  The  distension  disappears  gradually,  the  intestinal  walls  seem  to  regain 
their  power  of  contraction,  the  absorption  of  products  of  decomposition 
ceases  and  the  patient's  condition  improves  practically  in  all  cases  in  which 
the  intestines  still  contain  a  sufficient  amount  of  tone  to  force  their  contents 
back  into  the  stomach  by  return  peristalsis. 

The  emptying  of  the  intestines  above  the  point  of  obstruction  can  be 
further  facilitated  by  elevating  the  foot  of  the  bed,  which  favors  the  flow 
of  intestinal  contents  back  into  the  stomach  where  the  accumulation  will  be 
indicated  by  the  presence  of  nausea,  which  is  again  relieved  by  gastric  lavage. 
The  precaution  is  of  importance  moreover  because  it  will  protect  the  patient 
against  drowning  in  his  own  vomit,  an  accident  which  we  have  observed 
several  times. 

In  case  the  obstruction  is  due  to  the  wedging  of  a  fine  substance  into  a 
constriction  caused  by  the  presence  of  a  carcinoma  in  the  colon  the  method 
named  of  relieving  the  pressure  from  above  may  result  -in  its  dislodgment. 

Maury  has  shown  that  patients  with  intestinal  obstruction  are  severely 
poisoned  by  a  secretion  from  the  mucous  lining  of  the  duodenum, .  which 
explains  why  many  of  them  recover  so  splendidly  after  repeated  gastric 
lavages,  because  this  poisonous  substance  is  regurgitated  into  the  stomach 
and  washed  away  by  the  lavage. 

In  the  meantime  the  patient  is  supported  by  the  use  of  nutrient  enemata, 
one  ounce  of  liquid  predigested  food  being  dissolved  in  three  ounces  of  normal 
salt  solution  and  administered  through  a  soft  catheter  inserted  into  the 
rectum  a  distance  of  about  two  inches.  This  should  be  repeated  once  in  four 
hours.  If  the  patient  suffers  from  thirst  half  a  pint  of  normal  salt  solu- 
tion may  be  given  as  an  enema  in  the  same  manner  every  hour  until  the  thirst 
has  subsided.  It  is  important  not  to  introduce  the  catheter  a  greater  dis- 
tance than  about  two  inches  because  otherwise  one  frequently  observes  severe 
irritation. 

This  treatment  can  usually  be  continued  with  benefit  and  with  safety  for 


294 


GENERAL  SURGERY  OF  THE  ABDOMEN 


a  number  of  weeks.  In  many  cases  the  absence  of  irritation  and  pressure 
from  above  will  result  in  the  passage  of  gas  and  liquid  feces  through  the 
stricture,  because  there  is  always  a  certain  amount  of  edema  which  subsides 
when  the  irritation  has  disappeared. 


/ 


Intestinal  Anastomosis. 

End-to-end  with  Murphy  button;  (a)  button  in  place  with  purse-string  suture  tried:  (b) 
end  of  intestine  with  suture  in  place,  showing  manner  of  including  mesentery  at  (d)  ;  a  mesen- 
teric vessel  is  represented  as  tied  at  a  point  a  little  below  and  to  the  left  of  (d)  ;  (c)  represents 
the  remaining  half  of  the  button  to  be  introduced  into  the  segment  (b). 

It  is  best  not  to  give  any  food  by  mouth  to  these  patients,  after  the 
obstruction  has  once  been  complete,  until  the  hindrance  has  been  removed. 
Should  it  seem  necessary  to  postpone  the  operation  for  a  time  it  is  best  to 
continue  the  use  of  the  nutrient  enemata  and  to  give  only  such  nourishment 


GENERAL  SURGERY  OF  THE  ABDOMEN  295 

by  mouth  as  will  be  completely  absorbed  from  the  stomach  and  small  intes- 
tines. 

After  this  condition  of  relief  has  been  attained  in  cases  of  complete 
intestinal  obstruction  due  to  the  presence  of  carcinoma  in  the  colon,  the 
treatment  will  be  the  same  as  in  those  in  which  the  obstruction  is  not  com- 
plete. In  cases  in  which  the  stricture  remains  impermeable,  the  operation 
for  the  relief  of  the  obstruction  will  have  to  be  carried  out  at  a  time  which 
seems  favorable  in  the  judgment  of  the  surgeon  who  has  the  case  under 
.observation.  In  these  cases  there  can,  of  course,  be  no  further  preparatory 
treatment. 

Preparatory  treatment.  In  all  operations  upon  the  alimentary  canal  except 
in  the  presence  of  intestinal  obstruction  or  peritonitis,  it  is  well  first  to  remove, 
so  far  as  possible,  all  of  the  contents  thereof  by  the  administration  of  cathar- 
tics and  large  enemata  and  then  keeping  the  patient  on  sterilized  food  entirely 
until  the  time  of  the  operation.  It  is  well  to  repeat  the  cathartics  once  or 
twice,  if  the  patient's  condition  warrants  it,  in  order  to  remove  as  much 
as  possible  all  infectious  material  from  the  alimentary  canal.  Two  ounces 
of  castor  oil,  given  in  the  foam  of  beer,  ale  or  malt  extract,  is  usually  most 
effective  and  gives  rise  to  the  least  amount  of  irritation. 

Especial  stress  should  be  laid  upon  the  value  of  castor  oil  used  in  the 
manner  indicated  above.  From  time  to  time  we  have  tried  other  cathartics 
but  have  become  absolutely  convinced  of  the  fact  that  none  of  them  serves 
the  purpose  of  removing  septic  material  from  the  alimentary  canal  so  per- 
fectly as  this  remedy  when  given  in  this  dose  and  vehicle.  It  is  tasteless, 
non-irritating,  rarely  produces  nausea  or  vomiting  and  the  results  are  ideal. 

In  cases  in  which  there  is  but  a  small  opening  left,  but  which  is  still 
permeable,  we  often  give  two  ounces  of  castor  oil  once  or  twice  daily  for 
several  days  before  the  operation,  followed  by  the  administration  of  large 
normal  salt  solution  flushings  of  the  lower  bowl.  This  clears  up  the  patient's 
general  appearance  greatly,  as  they  have  usually  absorbed  fecal  material 
lodged  above  the  seat  of  obstruction  for  months  before  coming  under  our 
care.  Of  course  it  is  of  importance  in  the  meantime  not  to  give  food  which 
will  favor  further  accumulation. 

The  patient  may  chew  tender  broiled  steak  and  swallow  the  juice,  but  not 
the  pulp,  or  take  egg  albumen,  broth,  fruit  juices  and  milk  with  lime  water 
or  with  milk  of  magnesia. 

The  field  of  operation  is  prepared  in  the  usual  way. 

Technique  of  operation.  In  this  patient  the  tumor  can  be  located  defi- 
nitely, consequently  the  incision  will  be  made  in  a  position  facilitating  its 
removal.  It  is  not  possible  to  determine  the  exact  length  of  incision  that 
may  be  required  for  the  removal  of  this  tumor,  hence  we  must  choose  a  loca- 
tion for  the  incision  which  will  permit  of  its  enlargement.  We  will  choose 
the  outer  edge  of  the  right  rectus  abdominis  muscle.  This  may  be  lengthened 
indefinitely  if  it  should  seem  desirable  during  the  process  of  the  opera- 
tion. 

We  find  a  tumor  in  the  cecum  and  ascending  colon  beginning  a  little 
above  the  entrance  of  the  ileum  into  the  cecum.  The  tumor  is  about  twelve 
cm.  in  length  and  involves  the  entire  circumference  of  the  intestine.  It  is 
exceedingly  hard,  but  apparently  has  not  perforated  the  wall  of  the  bowel 
at  any  point.  It  seems  as  though  the  entire  growth  were  still  confined  to 
the  intestine  and  consequently  its  removal  may  result  in  a  permanent  cure.  At 
any  rate  it  is  certainly  worth  the  effort  to  attempt  securing  such  a  result. 

It  will  be  necessary  to  remove  the  entire  ascending  colon  together  with 
the  cecum.  We  must  consequently  plan  to  secure  a  union  between  the  ileum 
and  the  transverse  colon.    We  will  first  tear  an  opening  through  the  mesen- 


296 


GENERAL  SURGERY  OF  THE  ABDOMEN 


tery  of  the  ileum,  an  inch  from  its  entrance  into  the  cecum.  A  strong,  long- 
jawed  hemostatic  clamp  is  applied  to  the  ileum  on  the  side  toward  the  cecum. 
A  circular,  purse-string  suture  is  then  applied,  either  before  or  after  sever- 


,'V  / 


^^i;::;;;;;^^ 


Lateral  Anastomosis  of  Intestines  with  Murphy  Button. 

This  plate  does  not  show  the  end  of  the  intestine  properly ;  the  tissue  should  be  represented 
as  inverted  into  the  lumen  of  the  intestine  by  means  of  Lembert  sutures  at  (d)  and  (e).  At 
(a)  the  purse-string  suture  is  represented  as  applied  properly,  with  the  stitches  near  the  edge 
of  the  incision.  At  (b)  the  segment  of  the  button  is  in  place  and  the  purse-string  suture  has 
been  tied.  It  is  better  to  introduce  the  button  through  the  open  end  of  the  intestine  and  to 
make  a  very  small  puncture  of  the  wall,  just  suificient  for  the  central  portion  of  the  button 
to  protrude,  then  to  close  the  ends  of  the  intestine.  It  will  then  not  be  necessary  to  apply 
the  purse-string  sutures  at  (a)   and   (b). 

In  uniting  small  intestine  with  small  intestine  the  end-to-end  anastomosis  with  tlie  Murphy 
button  is  to  be  preferred  to  the  end-to-side  or  side-to-side  anastomosis.  In  uniting  small  intes- 
tine with  colon  an  end-to-side  anastomosis  with  the  Murphy  button  seems  most  satisfactory. 
In  uniting  colon  with  colon  a  lateral  anastomosis  with  needle  and  thread  or  with  the  McGraw 
ligature  seems  to  give  the  most  satisfactory  results. 

ing  the  intestine.  If  the  intestine  is  severed  before  the  suture  is  applied  we 
prefer  to  insert  the  latter  after  the  method  illustrated  in  the  plate,  because  this 
insures  the  holding  together  of  the  two  layers  of  the  mesentery,  as  well  as 


GENERAL  SURGERY  OF  THE  ABDOMEN  297 

inclusion  in  the  bite  of  the  Murphy  button  of  a  uniform  amount  of  each 
layer  of  the  intestinal  wall. 

Before  severing  the  intestine  an  assistant  should  grasp  it,  at  a  distance 
of  about  six  inches  from  the  cecum,  between  his  thumb  and  finger  to  prevent 
the  leakage  of  contents  while  the  button  is  put  in  place.  The  same  result 
may  be  accomplished  by  perforating  the  mesentery  between  the  large  vessels, 
which  can  readily  be  recognized,  and  tying  a  strand  of  aseptic  gauze  around 
the  intestine  just  sufficiently  firm  to  prevent  leakage.  It  is  well  to  draw 
a  snug-fitting  pledget  of  moist,  aseptic  cotton  through  the  button  to  prevent 
leakage  after  it  has  been  tied  into  the  end  of  the  intestine  and  before  it 
has  been  united  with  its  fellow.  The  smaller  portion  of  the  button  should  be 
employed  in  this  end  of  the  intestine.  The  button  is  inserted  and  the  purse- 
string  suture  is  tied  snugly  about  the  projecting  central  tube  of  the  button 
and  the  ends  are  cut  short.  Now  this  end  is  laid  aside  and  covered  with  a 
warm,  moist  pad  of  aseptic  gauze. 

The  cecum  is  now  lifted  out  of  the  abdominal  wound  by  means  of  the 
large  clamp-forceps  upon  the  small  portion  of  ileum  which  has  remained 
attached  to  the  cecum.  The  peritoneum,  together  with  its  blood  vessels,  is  now 
grasped  in  hemostatic  forceps,  both  to  the  inner  and  outer  side  of  the  cecum. 
Then  the  portion  between  is  cut  away  with  scissors.  In  this  way  the  cecum 
and  the  ascending  colon  can  be  freed  rapidly. 

As  the  operation  approaches  the  hepatic  flexure  of  the  colon  it  is  impor- 
tant to  proceed  cautiously  for  fear  of  clamping  the  duodenum,  together 
with  the  peritoneum  by  which  the  ascending  colon  it  attached.  In  this 
manner  the  hemorrhage  can  be  controlled  perfectly  and  the  excision  made 
rapidly.  Having  reached  the  hepatic  flexure  of  the  colon  we  are  at  least 
eight  cm.  beyond  the  tumor.  We  now  apply  two  pairs  of  heavy,  long- jawed, 
hemostatic  clamps  transversely  across  the  colon  and  cut  away  the  tumor  by 
severing  the  intestine  between.  This  will  prevent  any  leakage  from  either 
end  of  the  intestine.  All  of  the  vessels  which  have  been  clamped  are  now 
carefully  ligated  with  catgut.  At  any  point  at  which  there  seems  to  be  dan- 
ger of  the  ligature  slipping  off  it  is  best  to  place  a  catgut  suture  about  the 
part  included  in  the  grasp  of  the  hemostatic  forceps. 

It  is  well  to  bear  in  mind  the  fact  that  the  vessels  contained  in  the 
mesentery  have  a  tendency  to  retract,  and  that  for  this  reason  it  is  important 
to  exercise  great  care  in  their  ligation.  The  suggestion  made  by  W,  J.  Mayo 
to  split  the  peritoneum  along  the  inner  side  of  the  intestine,  expose  the 
vessels,  clamp  and  ligate  them,  is  a  very  good  one,  especially  when  the  mesen- 
tery is  not  deflnite  in  its  development,  because  in  this  way  every  possibility 
of  hemorrhage  due  to  slipping  of  stump  or  retraction  of  vessels  is  avoided. 

After  perfect  hemostasis  has  been  attained  a  suture  is  applied  to  the  sur- 
face of  the  transverse  colon  four  inches  from  its  end,  as  shown  in  accom- 
panying plate.  Care  should  be  taken  to  have  the  ascending  and  descending 
thread  in  this  suture  not  more  than  one-eighth  of  an  inch  apart.  The  intestine 
is  now  held  between  the  finger  and  thumb  of  an  assistant  six  inches  beyond 
this  point.  Its  end  is  enveloped  in  a  pad  of  moist,  aseptic  gauze.  The  clamp 
which  had  up  to  the  present  time  closed  the  cut  lumen  of  the  colon  is  removed. 
Any  bleeding  points  are  caught  with  hemostatic  forceps  and  ligated.  A  short 
cut,  see  plate,  a,  is  now  made  through  the  wall  of  the  colon,  half-way  between 
the  two  threads  of  the  suture.  The  Murphy  button  is  carried  into  the  lumen 
of  the  intestine  and  its  central  projecting  tube  is  carried  out  through  the 
incision  just  made.  The  ligature  is  tied  to  hold  the  button  firmly  in  place, 
although  this  is  scarcely  necessary,  because  the  opening  is  just  large  enough 
for  the  central  projecting  tube  of  the  button  to  protrude.  The  open  end 
of  the  colon  is  now  closed  by  two  rows  of  continuous  sutures  of  fine  silk, 


298 


GENERAL  SURGERY  OF  THE  ABDOMEN 


the  first  row  grasping  all  the  layers  and  the  second  row  of  Lembert  sutures 
serving  to  invert  the  first  row  into  the  lumen  of  the  colon.  The  pledgets 
of  cotton  occluding  the  central  tube  of  the  button  are  now  removed  and  the 
two  segments  of  the  button  are  united. 

This  completes  the  anastomosis.  After  carefully  sponging  off  the  surfaces 
and  covering  the  defect  in  the  peritoneum,  caused  by  the  removal  of  the 
cecum  and  ascending  colon,  with  surrounding  peritoneum,  by  means  of  a 
few  catgut  stitches,  the.  abdominal  wall  is  closed  in  the  usual  way. 

In  case  the  obstruction  has  been  complete  before  the  operation,  so  that 
the  patient  is  so  greatly  reduced  in  strength  that  it  seems  unwise  to  expose 
him  to  a  prolonged  operation,  it  is  best  to  make  the  anastomosis  between  the 
ileum  and  the  colon  at  the  first  operation,  in  order  to  re-establish  a  satisfac- 
tory communication  and  then  to  make  the  excision  of  carcinomatous  intes- 
tine after  the  patient's  strength  has  been  built  up. 


FjAteral   Anastomosis   Following   Excision    of   Cecum   and   Asending   Colon,   Between 
Lower  Ileum  and  Hepatic  Flexure. 
(Mayo.) 

Resection  of  cecum.  Two  precautions  seem  to  be  important  in  connec- 
tion with  the  excision  of  the  cecum  and  implantation  of  the  ileum  within 
the  colon. 

(1)  It  is  important  to  overcome  the  gas  pressure  in  the  colon  by  making 
a  thorough  dilatation  of  the  sphincter  ani  muscle  after  the  operation  has 
been  completed. 

(2)  Reder  has  suggested  the  wisdom  of  adding  a  temporary  colostomy 
to  this  operation  in  order  to  prevent  gas  pressure  and  in  order  to  enable 
the  surgeon  to  introduce  normal  salt  solution  into  the  colon  after  the  opera- 
tion, which  greatly  increases  the  comfort  of  the  patient  and  at  the  same 
time  decreases  the  shock  to  a  marked  extent.  A  Jacobs  retention  catheter  can 
be  placed  in  this  opening  at  the  time  of  the  operation,  which  will  facilitate 
the  introduction  of  normal  salt  solution.  The  opening  can  later  be  closed 
by  destroying  the  mucous  lining  with  actual  cautery. 

The  suture  method.  We  have  given  so  far  the  method  which  we  used 
exclusively  until  a  number  of  years  ago  because  it  was,  in  our  hands,  most 
satisfactory.  Since  that  time  we  have,  however,  discarded  all  mechanical 
means  for  securing  union  between  any  parts  of  the  gastro-intestinal  canal, 
not  because  the  ingenious  INIurphy  button  was  unsatisfactory  in  this  especial 
operation,  but  because  we  have  used  the  suture  method  thousands  of  times, 
especially  in  gastro-enterostomies,  and  have  consequently  acquired  the  habit 
of  doing  intestinal  work  by  the  suture  method  rapidly  and  satisfactorily. 


GENERAL  SURGERY  OF  THE  ABDOMEN 


299 


For  those  without  much  practice  in  gastric  or  intestinal  surgery  we  believe 
that  the  above  method  is  still  the  easiest  for  the  surgeon  and  the  safest  for 
the  patient,  and  that  in  this  operation  and  in  end-to-end  enterorrhaphy  we 
have  the  only  two  operations  in  which  it  is  proper  to  use  the  Murphy  button 
at  the  present  time.  In  all  other  operations  upon  the  gastro-intestinal  tract 
the  suture  method  should  be  used  exclusively.  The  Murphy  button  must 
always  remain,  however,  an  illustration  of  the  possibilities  of  surgical  inge- 
nuity of  the  highest  order. 

The  Murphy  button.  We  have  tested  the  usefulness  of  this  appliance 
in  a  large  number  of  these  operations,  and  have  found  that  it  is  most  satis- 
factory if  applied  properly.  The  important  points  to  be  borne  in  mind  in  its 
use  are : 

1.  The  button  must  be  well  made  and  must  be  kept  open  while  not 
in  use,  in  order  to  prevent  injury  to  the  spring. 

2.  The  silk  suture  must  grasp  all  of  the  layers  of  the  stomach  or  intes- 
tine, but  it  must  be  applied  very  near  the  edge  of  the  incision  in  order  not 
to  draw  too  much  tissue  into  the  bite  of  the  button. 


/ 

1                  s 

'~ , 

1 1^       ©^v 

fy 

/       ^' 

'Wf\'        a\ 

\ 

■1,'^- 

"k>' 

Murphy  Button. 

3.  The  incision  through  which  the  button  is  passed  must  not  be  too  large, 
just  large  enough  for  the  button  to  pass  through. 

4.  The  purse-string  suture  holding  the  button  must  be  tied  very  tightly 
and  the  ends  cut  short,  and  it  is  best  to  arrange  the  position  of  the  knot  so 
that  the  knots  in  the  two  segments  do  not  meet. 

5.  If  there  is  any  projection  of  mucous  membrane  after  the  purse-string 
suture  has  been  tied,  this  should  be  cut  away  before  the  two  segments  have 
been  united. 

6.  When  the  two  segments  have  been  united  there  should  be  a  perfectly 
smooth  union  throughout.  If  there  is  any  projecting  tissue  it  should  be 
pressed  in  between  the  segments  of  the  button  by  means  of  a  spatula  or  the 
flat  handle  of  a  scalpel. 

7.  No  sutures  should  be  applied  over  the  button. 

8.  The  button  must  be  placed  in  healthy  tissue,  never  in  the  near  vicinity 
of  an  ulcer  or  portion  of  the  intestine  which  is  in  danger  of  becoming  gan- 
grenous. 

Many  surgeons  object  to  the  use  of  an  appliance  which  has  to  remain 
in  the  intestine  in  the  form  of  a  foreign  body,  and  these  consequently  prefer 
a  suture  in  place  of  the  Murphy  button  or  other  appliance.  All  of  these 
operations  can  be  performed  satisfactorily  by  the  use  of  the  suture.  In  our 
own  work  we  have  usually  applied  silk  sutures  in  cases  in  which  we  did  not 
use  the  button,  but  many  surgeons  prefer  catgut. 

Since  publishing  the  third  edition  of  this  book  we  have  entirely  abandoned 
(as  has  been  previously  mentioned  herein)  the  use  of  mechanical  means  for 
the  purpose  of  uniting  intestines  with  other  intestines  or  with  the  stomach, 


300 


GENERAL  SURGERY  OF  THE  ABDOMEN 


not  because  of  any  bad  results,  but  rather  because  we  can  accomplish  the 
same  end  so  easily  with  the  use  of  needle  and  thread  and  because  we  prefer 
not  to  introduce  non-absorbable  objects,  and  because  the  suture  operation  can 
now  be  done  without  the  loss  of  much  time  and  with  excellent  results 

Rules  governing  sutures.     The  same  points  must  be  borne  in  mind  in  the 
use  of  sutures  as  m  the  use  of  the  button,  namely 

1.    The  surfaces  to  be  united  should  be  covered  with  peritoneum 
avoLd        "'''^'^'^*'  ''''''''^y  °^  t^^«  attachment  of  the  omentum  should  be 


_jKr/ toiei/TTi 

MvscU 7        /^      V    -     ; 

Intestinal  Anastomosis  :  End-to-End  with  Sutures. 

then  passiig  in  SZ  Zl^lTt  oppi'itl"    <  e'SS  Zluf  i"S  ™aa/to"L°'  S'  TlT'' 

S:e:":=aret-^ee.^fJ^t  :i.rr,,a?U^S.':S  e  ^^^ 

as  mterr^pted,  b.t  continuous  sutures  ma,  be  use'd  aS  ttaere'treteedl'rnJ^'CiTon' 


GENERAL  SURGERY  OF  THE  ABDOMEN  301 

3.  The  two  layers  composing  the  mesentery  should  be  held  together  hy 
a  carefully  applied  stitch,  and  the  mesentery  in  the  two  segments  should  not 
be  placed  in  accurate  apposition. 

4.  The  first  row  of  sutures  should  grasp  all  of  the  layers  of  the  intes- 
tinal wall,  but  the  needle  should  grasp  only  a  small  portion  of  each  layer. 

5.  The  second  row  of  sutures  should  be  applied  after  the  method  known 
as  Lembert  sutures,  which  penetrate  down  to,  but  not  through,  the  mucous 
membrane,  thus  placing  in  accurate  apposition  the  peritoneal  surface  through- 
out the  entire  extent  of  the  wound.  The  method  has  the  advantage  of 
affording  an  opportunity  to  make  the  anastomosis  as  large  as  one  may  desire. 
This  is  especially  advantageous  in  making  an  anastomosis  between  portions 
of  the  colon,  because  in  this  intestine  an  extensive  anastomosis  is  desirable. 
Interrupted  or  continuous  sutures  may  be  applied,  but  if  the  latter  form 
is  chosen,  it  is  well  to  take  a  back  stitch  every  fourth  or  fifth  stitch,  in 
order  to  insure  greater  security.  The  plate  illustrates  the  manner  in  which 
the  sutures  are  applied  in  an  end-to-end  anastomosis,  but  the  same  principle 
will  apply  in  a  side-to-side  or  an  end-to-side  anastomosis. 

After-treatment.  In  a  general  way  the  after-treatment  corresponds  to 
that  employed  in  gastro-enterostomy  with  the  difference  that  food  is  given 
by  mouth  a  little  earlier  and  that  active  cathartics  are  not  given  until  the 
button  has  been  passed,  when  the  Murphy  button  has  been  employed. 

In  the  suture  method  cathartics  are  not  given  until  the  end  of  the  second 
week,  and  the  food  is  very  carefully  selected  to  prevent  irritation;  predi- 
gested  foods,  buttermilk,  broth,  gruel,  egg-albumen,  are  most  useful. 

In  using  the  suture  method  in  place  of  the  Murphy  button  we  simply 
clamp,  ligate  and  invert  the  end  of  each  intestine  and  carefully  suture  it 
with  Lembert  sutures,  then  we  find  a  point  at  which  a  side-to-side  anastomosis 
between  any  portion  of  the  ileum  and  the  colon  can  be  made  without  making 
tension  upon  either  intestine,  then  we  make  an  enterostomy  at  least  five  cm. 
in  length,  using  the  same  method  by  means  of  clamps  and  sutures  that  has 
been  described  in  connection  with  gastro-enterostomy.  The  only  advantage 
this  operation  has  over  the  one  with  the  Murphy  button  lies  in  the  fact  that 
the  opening  can  be  made  larger  in  this  operation  than  in  the  previous  one. 

RESECTION  OF  THE  SMALL  INTESTINE 

This  operation  may  be  indicated  by  the  presence  of  gangrene  of  the 
intestine,  in  strangulated  hernia  or  in  volvulus,  by  severe  laceration  in  gun- 
shot or  other  wounds,  by  the  presence  of  tumors  or  circumscribed  tubercu- 
losis or  occasionally  in  cases  of  intussusception  accompanied  by  gangrene.  It 
may  also  be  indicated  by  the  presence  of  cicatricial  stricture  or  intestinal 
fistula.  The  procedure  itself  is  very  simple  and  more  depends  upon  the  proper 
selection  of  tissue  than  upon  the  technique  of  the  operation  itself.  "When- 
ever the  operation  is  performed  in  the  presence  of  gangrene  care  must  be 
taken  to  go  a  considerable  distance  beyond  the  suspicious  tissue.  A  patient 
is  much  safer  if  one  yard  of  intestine  has  been  sacrificed  unnecessarily,  than 
he  would  be  if  the  incision  were  made  at  the  very  border  of  the  gangrenous 
tissue. 

Technique.  In  excising  diseased  intestine  it  is  well  to  grasp  the  mesen- 
teric vessels  carefully  as  one  progresses  and  to  ligate  them  before  resecting 
the  intestine.  In  case  it  does  not  seem  safe  to  apply  simple  ligatures  the 
mesentery  may  be  transfixed  with  sutures,  in  order  to  prevent  slipping. 

After  a  sufficient  amount  of  intestine  has  been  separated  from  its  attach- 
ment to  the  mesentery,  care  is  taken  to  stop  at  a  point  sufficiently  distant 
from  a  large  branch  of  the  mesenteric  artery  to  prevent  the  injury  of  the 


302 


GENERAL  SUEGERY  OF  THE  ABDOMEN 


1.  Insertion  of  mesenteric  stitch,  -nhicli  oliliterates  triangular  space. 

2.  Mesenteric  stitch,  and  stitch  at  convex  Vjorder  inserted  and  tied,  with  ends  left  long 
for  traction.     Intervening  stitches  in  place. 


3.  First,   posterior,   half   completed,    -with   first   stitch   in   second,   anterior,   half   inserted, 
ready  for  tying. 


4.  Stitches  similar  to  one  shown  in  Fig  3,  inserted  throughout  the  anterior  half,  all  tied 
but  the  last  stitch.     This  in  place,  with  ends  ready   for  tying. 

5.  Threaded  needle  is  inserted  eye  first  between  two  stitches  into   the  lumen,  at  a  point 
in  the  circumference  about  opposite  to  tlie  stitch  to  be  tied. 

Illustrating  the  Connell  Method  of  Suturing.    (Courtesy  of  Dr.  Gregory  Connell.) 


GENERAL  SURGERY  OF  THE  ABDOMEN 


303 


6.  The  threaded  needle  presents  at  the  location  of  the  last  stitch.  The  ends  to  be  tied 
are  inserted  into  the  loop  formed  by  the  needle  and  its  thread. 

7.  By  -withdrawal  of  the  needle  and  its  loop,  the  cut  ends  at  the  site  of  the  last  stitch 
are  inverted,  and  the  ends  to  be  tied  are  drawn  to  the  outside  through  the  opposite  portion  of 
the  line  of  suture. 


■»5-S«-;!*7ig|«s«^^ 


.^^^^ 


8.  Traction  on  suture  ends  causes  the  site  of  the  future  knot  to  come  in  contact  with  the 
mucosa  of  the  opposite  side  of  the  bowel.  The  ends  are  tied,  the  knot  sinks  between  the  previ- 
ously inserted  stitches  and  is  located  on  the  mucosa. 

9.  The  last  knot  is  tied,  the  bowel  has  resumed  its  cylindrical  contour,  and  the  enteror- 
rhaphy  is  complete,  with  all  knots  in  the  lumen. 

Illustkating  the  Connell  Method  of  Suturing.     (Courtesy  of  Gregory  Coxnell.) 


304  GENERAL  SURGERY  OF  THE  ABDOMEN 

latter.  The  intestine  is  now  held  on  either  side  by  the  hand  of  an  assistant 
to  prevent  leakage,  or  this  may  be  done  by  passing  a  narrow  strip  of  gauze 
through  the  mesentery  and  tying  just  tightly  enough  to  prevent  extrusion. 
Then  a  large  pair  of  long-jawed,  clamp  forceps  is  applied  to  either  side  of 
the  portion  to  be  excised,  in  order  to  prevent  leakage  from  this  portion.  Then 
the  intestine  is  cut  away  at  either  side,  care  being  taken  to  cut  away  a  little 
more  from  the  point  opposite  the  mesentery  than  on  the  mesenteric  side. 

Aside  from  protecting  the  tissue  against  gangrene  this  method  results  in  a 
little  increase  in  lumen  at  the  point  at  which  the  enterorrhaphy  is  made,  which 
is  probably  of  importance  especially  in  cases  in  which  this  is  accomplished  by 
the  suture  method.  "When  the  ]\Iurpny  button  is  used  there  is  never  any  nar- 
rowing at  the  point  of  union,  because  the  cicatricial  tissue  formed  is  so  slight 
that  it  can  hardly  be  discovered  by  the  unaided  eye. 

Silk  stitches  are  then  applied,  being  cautious  to  pass  the  stitch  around  the 
mesentery  so  as  to  hold  its  two  surfaces  together.  The  larger  segment  of  the 
Murphy  button  is  adjusted  to  the  lower  segment  and  the  smaller  one  to  the 
upper,  and  then  the  two  segments  are  adjusted  to  each  other.  It  is  well  to 
turn  them  a  little  so  that  the  mesentery  of  the  one  part  does  not  fall  directly 
opposite  to  the  mesentery  of  the  other.  A  few  sutures  should  be  applied  to 
cover  the  defect  caused  by  the  excision  of  the  intestine  in  order  to  prevent 
unnecessary  adhesions  to  the  denuded  surfaces. 

In  this  operation  we  now  use  the  suture  method  exclusively,  applying  one 
row  of  sutures  which  grasps  all  of  the  layers  to  secure  accurate  coaptation 
and  to  control  the  hemorrhage.  This  row  of  sutures  carefully  brings  together 
the  mesenteric  attachment  so  as  to  prevent  leakage  at  this  point.  A  second 
row  of  continuous  Lembert  sutures  is  applied  over  the  -first  row  of  sutures  in 
order  to  unite  peritoneum  to  peritoneum  throughout.  This  method  was  intro- 
duced by  Czerny  many  years  ago  and  is  still  very  satisfactory. 

Gregory  Connell  has  introduced  the  following  method  which  is  also  most 
excellent,  although  it  requires  somewhat  more  dexterity  and  accuracy  than 
that  just  described. 

The  Connell  method.  Nothing  can  be  more  perfect  for  an  end-to-end  anas- 
tomosis of  the  small  intestine  than  this  or)eration  when  performed  by  its  author 
or  by  any  one  who  has  operated  sufficiently  often  upon  animals  to  obtain  a 
high  degree  of  accuracy.  Each  successive  suture  leaves  the  serous  surfaces  in 
ideal  coaptation,  as  shown  bv  the  accompanying  illustrations,  and  when  the 
operation  has  been  completed  every  suture  is  perfectly  buried.  There  can  be 
no  hemorrhage  because  the  sutures  grasp  every  portion  of  the  intestinal  wall. 
The  mesenteric  attachment  has  been  closed  so  that  there  can  be  no  perforation 
at  this  treacherous  point  and  there  is  no  possibility  of  obstruction  at  the  point 
of  union  between  the  two  segments.  The  operation  is,  however,  too  difficult 
technically  to  be  undertaken  by  an  unskilled  surgeon,  who  might  still  be  able 
to  safely  "close  both  ends  of  the  intestine  and  make  the  lateral  anastomosis 
described  above. 

Steps  of  the  operation.  The  various  steps  of  the  operation  have  been  so 
accurately  described  by  Gregory  Connell.  its  author,  in  connection  with  his 
illustrations  that  its  seems  impossible  to  misunderstand  any  detail,  and  in  order 
to  acquire  the  necessary  skill  to  perform  this  operation  it  is  but  necessary  to 
do  it  repeatedly  upon  dogs. 

A  dozen  operations  can  safely  be  made  upon  a  single  animal  if  the  surqreon 
will  work  as  rapidly  as  he  can,  and  if  ether  is  administered  carefully  to  the 
animal  it  consequently  will  not  require  manv  animals  to  acquire  proficiency. 
The  excision  of  the  diseased  portion  having  been  made  and  the  bleeding 
from  the  mesenteric  attachment  controlled  the  first  suture  is  applied  from 
within  outward,  just  outside  of' the  mesenteric  attachment,  then  it  is  carried 


GENERAL  SURGERY  OF  THE  ABDOMEN  305 

across  to  the  other  side  and  passed  from  without  inward  again  just  outside 
of  the  mesentery,  then  it  is  carried  across  to  the  other  side  and  is  passed  into 
the  lumen  of  the  intestine  where  the  suture  is  tied,  perfectly  closing  the  mesen- 
teric attachment.  The  sutures  from  this  point  on  are  applied  as  indicated  in 
the  illustrations. 

RESECTION  OF  THE  COLON 

Should  it  become  requisite  to  resect  the  colon  we  are  confronted  with  a 
condition  which  is  somewhat  different,  inasmuch  as  the  posterior  surface  of 
the  colon  is  not  covered  with  peritoneum.  This  makes  an  anastomosis  much 
more  troublesome,  because  union  is  much  less  certain  in  portions  of  the  intes- 
tine not  covered  with  peritoneum.  In  order  to  overcome  this  difficulty  it  is 
best  to  close  the  ends  of  the  colon  and  make  a  side-to-side  anastomosis  of  the 
two  ends,  choosing  for  this  the  surfaces  covered  with  peritoneum. 

In  the  transverse  colon  it  is  especially  important  not  to  infringe  upon 
the  attachment  of  the  omentum  for  fear  of  causing  subsequent  necrosis.  This 
anastomosis  should  never  be  made  by  m.eans  of  a  ^lurphy  button,  as  there 
is  liable  to  be  an  accumulation  of  hardened  feces  in  the  upper  segment,  which 
would  be  likely  to  obstruct  the  lumen  of  the  button,  for  this  reason  it  seems 
best  always  to  make  an  anastomosis  by  means  of  sutures.  It  is  usually  still 
better  to  close  both  ends  of  the  large  intestine  and  make  an  anastomosis  be- 
tween the  ileum  and  the  colon  below  the  point  of  resection,  as  in  this  way 
one  secures  the  flow  of  liquid  contents  of  the  small  intestine  into  the  colon. 
In  this  case  the  button  is  perfectly  safe  but  we  now  alwaj^s  use  the  suture. 

If  this  plan  is  followed  it  is  best  to  excise  all  of  the  colon  on  the  proximal 
side  of  the  malignant  growth  to  prevent  accumulation  of  fecal  material  in 
this  portion,  and  it  is  usually  most  convenient  to  make  the  anastomosis  be- 
tween the  ileum  and  the  sigmoid  flexure,  because  at  this  point  the  anastomosis 
can  be  effected  without  any  tension  upon  either  segment. 

The  end  of  the  colon  is  closed  by  applying  a  strong  pair  of  forceps  across 
the  intestine  at  the  point  at  which  the  resection  is  contemplated.  This  will 
crush  the  soft  tissues  out  of  the  grasp  of  the  forceps  and  leave  only  the  fibrous 
tissue  in  place.  Then  a  silk,  purse-string  suture  is  applied  to  the  proximal 
side  of  these  forceps.  This  is  tied  tightly,  which  will  cause  it  to  be  buried 
in  the  groove  made  by  the  heavy  forceps.  Then  the  diseased  portion  is  cut 
away,  leaving  the  portion  of  the  tissue  held  by  the  purse-string  suture  to 
project  from  the  part  of  the  intestine  which  is  left.  This  is  then  buried  in  the 
end  of  the  intestine  by  the  application  of  a  row  of  Lembert  sutures. 

Gibson  method.  The  most  satisfactory  operation  for  end-to-end  anastomo- 
sis of  the  lower  end  of  the  colon  that  we  have  employed  is  that  introduced  by 
C.  L.  Gibson  which  we  will  describe  in  his  own  words. 

The  method  has  the  advantage  of  extreme  simplicity.  It  provides  for  a 
broad  union  of  peritoneal  surfaces  and  it  reduces  the  tension  necessary  to  a 
minimum. 

The  anastomosis  does  not  result  in  any  narrowing  at  the  line  of  suturing. 

"The  upper  cut  edge  of  the  gut  is  seized  with  two  Kocher  clamps  and 
introduced  by  these  into  the  lumen  of  the  lower  end  and  maintained  there 
by  an  assistant.  The  extent  to  which  it  is  feasible  to  accomplish  this  invag- 
ination will  vary,  depending  on  the  laxity  of  the  mesentery.  If  the  latter  is 
very  short  it  may  be  elongated  somewhat  by  a  generous  incision  of  its  outer 
layer.  As  a  general  rule  I  should  wish  to  carry  the  cut  end  of  the  upper 
segment  so  far  down  as  possible,  hoping  more  efficiently  to  direct  the  fecal 
current  away  from  the  suture  line.  The  gut  is  rotated  about  a  quarter  circle 
so  that  the  non-peritoneal  covered  surfaces  do  not  entirely  approximate  in 


306  GENERAL  SURGERY  OF  THE  ABDOMEN 

the  circumference.  Eight  to  twelve  interrupted  silk  sutures  are  introduced 
thus.  A  Lembert  suture  is  begun  on  the  lower  segment,  the  needle  issuing 
just  short  of  the  cut  edge ;  on  the  upper  segment  the  needle  is  introduced  just 
above  the  line  where  the  cut  edge  of  the  lower  segment  lies  against  the  intact 
wall  of  the  upper.  When  the  knot  is  tied  the  free  cut  edge  has  been  turned 
inward  and  only  the  peritoneal  surfaces  are  in  contact.  A  continuous  running 
suture  is  applied  over  this  area  further  invaginating  the  first  ones,  the  Kocher 
clamps  being  previously  withdrawn." 

After-treatment.  In  a  general  way  the  after-treatment  in  which  the  colon 
is  involved  in  the  operation  is  the  same  as  in  operations  upon  the  stomach  or 
the  small  intestines ;  only  predigested  foods  are  given  by  mouth  from  the  third 
day  on  and  nourishment  by  enema  is  not  employed.  Hot  water  in  small  sips 
is  given  by  mouth  shortly  after  the  operation  and  continued  for  the  first  few 
days. 

One  can  easily  choose  a  predigested  food  which  is  absorbed  almost  entirely 
from  the  stomach  and  small  intestines  which  will  sustain  the  patient  until 
the  union  between  the  joined  ends  of  intestine  is  sufficiently  firm  to  make  the 
use  of  general  liquid  diet  safe.  Ordinarily  a  very  firm  union  exists  after  the 
third  day,  but  occasionally  the  patients  in  whom  these  operations  are  indicated 
are  much  reduced  in  strength  and  consequently  their  tissues  do  not  heal  so 
rapidly, 

INGUINAL  COLOSTOMY 

The  only  pathological  condition  indicating  an  inguinal  colostomy  is  a 
stricture  of  the  rectum  which  cannot  be  excised.  This  may  be  due  to  carcinoma 
or  cicatricial  contraction  following  a  tubercular  or  a  syphilitic  ulcer,  or  an 
acute  infection. 

The  operation  may  be  intended  only  for  temporary  relief  until  the  con- 
stricted portion  of  the  rectum  may  be  excised  and  the  continuity  between  the 
intestine  above  and  below  this  constriction  has  again  been  established,  or  it 
may  be  for  permanent  use.  If  it  is  intended  only  for  temporary  effect  it  is 
not  necessary  to  provide  for  a  means  of  keeping  this  opening  closed  at  times 
to  guard  against  the  involuntary  evacuation  of  the  bowels.  If  the  intestine 
is,  however,  intended  to  remain  permanently  open,  it  is  desirable  to  secure 
such  a  provision.  For  the  sake  of  brevity  we  describe  only  the  latter  opera- 
tion, because  it  happens  frequently  that  a  colostomy  which  is  primarily  in- 
tended to  be  only  for  temporary  relief  will  later  be  maintained  permanently, 
either  because  it  is  not  possible  to  establish  a  satisfactory  communication 
through  the  natural  way,  or  because  the  patient  is  so  comfortable  that  he 
refuses  to  submit  to  the  necessary  operation  to  establish  the  communication 
through  the  rectum. 

Technique.  An  incision  is  made  parallel  with  Poupart's  ligament,  two  and 
one-half  inches  in  length,  two  inches  above  the  anterior  superior  spine.  Its 
center  is  crossed  by  a  line  extending  from  the  left  anterior  superior  spine  of 
the  ileum  to  the  umbilicus.  This  incision  extends  down  through  the  external 
oblique  abdominal  muscle,  whose  fibers  it  separates  but  does  not  cut. 

The  internal  oblique  abdominal  muscle  is  then  separated  in  the  direction 
of  its  fibers,  which  extend  nearly  at  right  angles  with  the  fibers  of  the  ex- 
ternal oblique.  Then  the  transversalis  fascia  and  peritoneum  are  severed  in 
the  same  direction.  This  incision  corresponds  exactly  to  the  McBurney  in- 
cision, which  has  been  described  in  the  section  on  appendicitis,  with  the 
exception  that  it  is  on  the  left  instead  of  the  right  side  of  the  abdomen. 
With  this  incision  the  two  abdominal  muscles  are  not  impaired,  because  none 


GENERAL  SURGERY  OF  THE  ABDOMEN 


307 


of  their  fibers  have  been  cut  at  right  angles,  and  they  are  in  a  condition  in 
which  they  can  readily  act  as  sphincter  muscles. 

A  second  incision  is  now  made  parallel  with  the  first  and  of  the  same  length, 
but  four  cm.  nearer  the  anterior  superior  spine  of  the  ileum.     A  third  in- 


End-to-End  Anastomosis  of  Colon. 

1.  The  intestine  is  clamped  with  large  forceps  whose  jaws  are  covered  with  rubber  tubing 
to  prevent  injury  to  tissues.     By  courtesy  of  Dr.  C.  L.  Gibson. 

cision  uniting  these  two  at  the  upper  end  is  made  and  the  flap  of  the  skin 
thus  formed  is  dissected  loose  and  covered  temporarily  by  a  piece  of  moist 
antiseptic  gauze.  The  finger  is  then  inserted  into  the  abdominal  cavity  and 
passed  along  the  ilium  until  it  reaches  the  sigmoid  flexure  of  the  colon.    This 


End-to-End  Anastomosis  of  Colon. 

2.  The  upper  segment  is  invaginated  into  the  lower  and  a  Lembert  suture  has  been  applied 
which  will  invert  the  cut  end  of  the  lower  segment  when  tied.    By  courtesy  of  Dr.  C.  L.  Gibson. 

is  withdrawn  through  the  incision  in  the  abdominal  wall.  It  can  readily  be 
recognized  as  large  intestine  from  the  fact  that  the  longitudinal  band  of  muscle 
fibers  extends  parallel  with  its  upper  surface  and  that  there  are  attached  to 
it  numerous  masses  of  fat,  the  appendices  epiploica.  It  is  best  to  bring  out 
the  upper  segment  of  the  sigmoid  as  much  as  possible,  in  order  to  prevent  it 


308 


GENERAL  SURGERY  OF  THE  ABDOMEN 


from  prolapsing  later  on,  a  condition  which  occurs  frequently  in  cases  in  which 
this  precaution  has  not  been  taken. 

The  intestine  is  now  held  up  to  the  light  in  order  to  select  a  point  in  its 
mesentery  through  which  an  opening  may  be  torn  without  disturbing  any  of 


End-to-End  Anastomosis  of  Colon. 

3.  The  compressing  forceps  have  been  removed  and   the   cut  end   of   the  lower   segment 
inverted.     By  courtesy  of  Dr.  C.  L.  Gibson. 

the  large  blood  vessels.  This  opening  must  be  sufficiently  large  to  admit  the 
skin  flap  which  has  been  prepared.  The  upper  segment  of  the  intestine  is 
then  placed  outward  and  the  lower  segment  inward  and  the  skin  flap  is 
drawn  through  the  opening  in  the  mesentery.     In  this  manner  the  upper  seg- 


End-to-End  Anastomosis  of  Colon. 

4.   The  completed  operation  with  exception  of  tying  sutures  and  introducing  further  sutures 
of  the  same  kind.     By  courtesy  of  Dr.  C.  L.  Gibson. 

ment  is  bent  over  the  outer  edge  of  the  abdominal  wall  and  underneath  the 
skin  flap.  Consequently,  after  healing  has  taken  place  the  application  of  a 
pad  over  this  part  will  cause  the  skin  flap  to  act  like  a  valve  and  will  prevent 
the  involuntary  evacuation  of  the  bowel  contents.  The  incisions'  are  now 
closed.     In  order  to  prevent  any  protrusion,  a  few  stitches  are  inserted  at- 


GENERAL  SURGERY  OF  THE  ABDOMEN  309 

taching  the  intestine  to  the  skin.     The  operation  is  shown  in  the  accompany- 
ing plate. 

The  loop  of  intestine  is  not  opened  until  adhesions  have  formed,  unless 
this  is  necessary  on  account  of  complete  obstruction,  in  which  case  the  wound 
is  carefully  protected  and  a  large  rubber  tube  covering  a  short  glass  tube  is 
inserted  into  the  upper  segment  and  securely  fastened  by  means  of  a  strong, 
purse-string  suture.  This  will  compel  the  contents  of  the  intestine  to  pass 
out  through  the  tube,  which  is  passed  through  the  dressing,  without  soiling 
the  wound.  If  this  is  not  necessary  a  dressing  is  applied  which  will  permit 
the  gas  to  pass  through  this  loop.  Cotton  is  rolled  in  long  bundles  and  these 
are  applied  about  the  protruding  intestine  after  the  fashion  of  logs  in  a  log 
cabin.  These  bundles  are  held  in  place  by  means  of  broad  adhesive  strips  and 
an  abdominal  bandage. 

After  from  two  to  five  days  the  intestine  is  cut  across  and  then  the  evacua- 
tions can  occur  without  interfering  with  the  healing  of  the  wound.  Aside 
from  the  advantage  there  is  in  securing  a  means  of  closing  the  upper  segment 
when  desired,  this  method  has  the  further  value  of  leaving  the  two  openings 
of  the  intestine  so  far  apart  that  there  can  be  no  passage  of  feces  from  the 
upper  into  the  lower.  The  evacuations  will  now  occur  through  the  opening  a, 
which  is  sufficiently  separated  from  the  opening  b,  communicating  with  the 
segment  leading  to  the  rectum,  to  prevent  any  of  the  evacuations  from  finding 
their  way  into  this  canal.  This  portion  of  the  intestine  can,  however,  be 
cleansed  by  irrigating  through  this  opening. 

In  case  it  should  become  desirable  later  on  to  close  the  artificial  anus  this 
may  be  accomplished  by  inserting  one  branch  of  a  clamp  through  each  of 
these  openings  and  gradually  tightening  the  pressure  until  a  communication 
has  been  established,  when  the  openings  can  readily  be  closed. 

After-treatment.  Until  the  protruding  loop  has  been  cut  only  hot  water 
and  small  quantities  of  predigested  food  are  given  by  mouth.  After  this  time 
general  liquids,  and  after  a  week  light  diet  is  given. 

This  operation  is  usually  performed  in  old  persons  greatly  reduced  in 
strength  and  such  do  not  well  bear  lying  quietly  in  bed.  It  is  consequently 
best  to  permit  them  to  occupy  a  semi-sitting  position  within  a  day  or  two 
after  the  operation,  and  to  leave  the  bed  within  a  week  or  ten  days  later. 

After  the  intestine  has  been  opened  a  cathartic,  preferably  castor  oil, 
should  be  given,  and  this  should  be  followed  by  several  enemata  in  order  to 
remove  fecal  accumulations  which  frequently  exist  in  large  quantities  above 
the  constriction,  even  if  a  diligent  attempt  has  been  made  to  evacuate  the 
bowels  before  the  operation.  Frequently  the  lower  segment  contains  many 
of  these  masses,  which  may  usually  be  removed  by  irrigation  but  may  occa- 
sionally require  a  blunt  scoop.  It  is  well  to  examine  the  opening  by  inserting 
the  finger  within  the  lumen  of  the  intestine  through  the  abdominal  wall, 
because  occasionally  not  sufficient  space  has  been  allowed  for  the  evacuation 
of  the  bowels  and  the  free  passage  of  gas.  This  can  be  remedied  readily  by 
a  slight  incision. 

These  patients  should  be  instructed  to  regulate  their  diet  so  as  to  avoid 
constipation  and  then  to  take  a  simple  cleansing  enema  once  a  day  to  insure 
a  free  evacuation  of  the  bowels.  Thus  they  can  usually  be  entirely  free  from 
any  annoyance  because  of  the  artificial  anus.  A  small  pad  of  cotton  should 
be  worn  over  the  opening,  held  in  place  by  a  simple  abdominal  bandage.  In 
case  there  is  any  annoyance  from  escaping  feces  a  substantial  pad  may  be 
held  in  place  over  the  opening  by  means  of  an  elastic  bandage,  which  will 


310 


GENERAL  SURGERY  OF  THE  ABDOMEN 


compress   the   intestine   underneath   the   skin  flap   c,   over  the   edge    of  the 
abdominal  wound  sufficiently  to  overcome  this  annoyance. 

If  there  is  not  enough  force  in  the  colon  to  produce  an  evacuation,  it 
is  sometimes  best  to  insert  a  large  rectal  tube  after  giving  the  enema  and  to 
effect  the  evacuation  through  this. 


Inguinal  Colostomy. 

The  colon  is  drawn  out  tlirough  the  incision  in  the  abdominal  wall;  its  mesentery  is 
split;  a  rectangular  ilap  of  skin  is  cut  and  drawn  through  the  slit  in  the  mesentery  and  sutured 
in  place.  The  longitudinal  muscular  band  is  shown  ujion  the  surface  of  the  sigmoid  flexure 
of  the  colon. 

The  intestine  will  be  cut  across  at  the  point  indicated  by  the  dotted  line,  the  openings 
will  then  retract  to  the  points  a  and  b. 


Alternative  procedure.  In  cases  in  which  it  is  plain  at  the  time  of  the  opera- 
tion that  it  will  never  be  possible  to  re-establish  communication  between  the 
upper  and  lower  segments,  on  account  of  the  obstruction  in  the  rectum,  we 
prefer  to  perform  an  operation  which  carries  out  the  upper  segment  through 
the  abdominal  wall.  This  is  required  especially  in  cases  of  carcinoma  in  which 
the  growth  has  invaded  the  surrounding  tissues  to  such  an  extent  that  a  com- 
plete removal  is  impossible. 


GENERAL  SURGERY  OF  THE  ABDOMEN  311 

In  this  operation  the  first  steps  are  the  same  as  those  described  above 
but  instead  of  forming  a  skin-flap  to  carry  underneath  the  loop  of  intestine 
the  second  incision,  five  cm.,  is  made  parallel  to  the  first  and  the  skin  and 
superficial  fascia  are  undermined  so  as  to  form  a  tunnel  through  which  the 
upper  segment  of  the  colon  is  later  to  be  carried,  then  the  abdomen  is  opened 
a  second  time  through  a  median  incision  ten  to  fifteen  cm.  long  between  the 
umbilicus  and  the  pubis.  The  sigmoid  flexure  is  brought  out  through  this 
opening,  its  mesentery  is  clamped  and  ligated  according  to  the  method  de- 
scribed in  excision  of  the  colon.  About  ten  to  flfteen  cm.  of  the  intestine 
is  made  free  from  the  mesentery,  then  two  large  clamps  are  applied  trans- 
versely, at  a  point  leaving  enough  tissue  in  connection  with  the  lower  segment 
to  make  sure  that  the  upper  segment  is  at  least  ten  cm.  beyond  any  diseased 
tissue  and  at  the  same  time  enough  to  make  an  inversion  of  the  free  end 
of  this  segment  into  its  lumen  easily  possible.  The  upper  segment  must 
contain  a  sufficient  amount  of  free  bowel  to  reach  through  the  inguinal  opening 
and  through  the  canal  underneath  the  skin-flap,  and  beyond  the  margin  of  the 
second  incision,  without  the  slightest  tension. 

The  end  of  the  lower  segment  is  then  ligated  and  inverted  into  its  lumen 
and  the  wall  closed  over  it  with  a  purse-string  suture  which  is  reinforced 
with  a  row  of  Lembert  sutures. 

The  upper  segment  is  then  also  ligated  to  prevent  the  escape  of  any  con- 
tents, then  it  is  carefully  covered  with  gauze  and  carried  out  through  the 
inguinal  incision  and  underneath  the  skin -flap  where  it  is  sutured  in  place,  so  as 
to  project  at  least  one  cm.  beyond  the  surface  of  the  skin.  A  few  sutures  are 
applied  between  the  wall  of  the  bowel  and  the  peritoneum  and  transversalis 
fascia  at  the  inguinal  wound  in  order  to  support  the  segment  and  at  the  same 
time  to  prevent  any  loop  of  the  small  intestine  from  being  forced  out  along 
the  side  of  the  colon. 

Then  the  woiuids  are  all  sutured  and  the  same  dressing  is  applied  as  in  the 
previous  operation. 

It  is  important  to  determine  which  is  the  proximal  and  which  the  distal 
segment  because  in  these  cases  with  long-continued  obstruction  the  sigmoid 
flexure  is  often  very  long  and  sometimes  twisted  upon  its  mesentery  so  that  it 
is  quite  possible  to  confound  the  two  segments.  This  would,  of  course,  be  a 
fatal  error  unless  it  were  discovered  in  time  to  be  remedied. 

The  after-treatment  is  the  same  as  in  the  previous  operation,  the  ligature 
closing  the  upper  segment  is  removed  on  the  second  or  third  day.  It  is  im- 
portant in  this  operation  not  to  permit  any  fecal  matter  to  remain  in  the  lower 
segment  above  the  point  of  constriction,  as  this  might  result  in  perforation. 

In  many  of  these  cases  the  removal  of  irritation  caused  by  the  passage  of 
fecal  material  over  the  surface  of  the  carcinoma  will  cause  the  malignant 
growth  to  remain  stationary  in  its  development  for  a  long  time. 

"We  have  seen  many  of  these  patients  take  on  a  normal  appearance,  gain 
greatly  in  weight,  return  to  their  occupation  and  imagine  themselves  cured 
for  months  or  even  years.  This  is  true  especially  in  cases  of  very  slow  grow- 
ing annular  carcinoma  of  the  rectum  in  which  the  bad  condition  of  the  patient 
is  due  to  prolonged  absorption  of  fecal  material  which  had  accumulated  above 
the  seat  of  obstruction  before  this  condition  was  relieved  by  establishing  a 
colostomy. 

SIR  ARBUTHNOT  LANE'S  SURGICAL  TREATMENT  FOR  CONSTIPATION 

Several  years  ago  our  attention  was  directed  by  Lane  to  the  fact  that  many 
patients  suffer  severely  from  the  results  of  absorption  of  putrid  substances 
from  a  colon  containing  enormous  quantities  of  fecal  matter  prevented  from 
being  evacuated  normally.    Lane  demonstrated  the  fact  that  these  accumula- 


312  GENERAL  SURGERY  OF  THE  ABDOMEN 

tions  remain  indefinite  periods  of  time,  the  evacuations  that  may  occur  from 
time  to  time  never  emptying  more  than  the  lowest  portion,  and  frequently 
passing  directly  b}^  the  accumulations  in  the  colon  on  their  way  from  the 
ileum  to  the  rectum. 

This  condition  is  due  to  faulty  development  as  regards  the  position  espe- 
cially of  the  cecum  and  transverse  colon,  the  latter  usually  having  its  position 
low  down  in  the  abdominal  cavity.  It  is  further  exaggerated  by  constricting 
or  obstructing  bands,  and  still  further  bj-  habitual  neglect  on  the  part  of  the 
patient  to  secure  regular,  complete  daily  evacuation  of  the  bowels. 

When  the  transverse  colon  and  the  cecum  have  once  become  permanently 
loaded  with  hardened  feces  the  weight  of  the  mass  itself  will  result  in  the 
dropping  down  of  the  cecum  and  transverse  colon,  and  this  in  turn  will  serve  to 
still  further  increase  the  condition  of  constipation. 

In  many  of  these  cases  Lane  has  obtained  remarkable  results,  restoring 
patients  who  were  complete  physical  and  nervous  wrecks  to  good  health  and 
strength  by  exercising  the  entire  colon  and  implanting  the  ileum  into  the 
sigmoid  or  into  the  upper  portion  of  the  rectum  •,  or  in  milder  cases  by  resecting 
the  ileum  fifteen  cm.  from  its  entrance  into  the  cecum  and  implanting  the 
proximal  end  into  the  sigmoid  flexure. 

The  following  description  of  the  various  steps  of  the  operation  is  taken 
from  Lane's  work  on  this  subject.  AVe  have  performed  the  operation  several 
times  ^^■ith  satisfactory  results  and  have  seen  a  number  of  Lane's  patients, 
all  of  whom  showed  excellent  recoveries. 

Lane's  technique.  "In  no  circumstances  should  operative  interference  be 
contemplated  till  the  surgeon  has  satisfied  himself  that  every  other  means  of 
treatment  have  failed,  whether  medical  or  mechanical. 

"In  the  treatment  of  such  degrees  of  overloading  of  the  large  bowel  as 
cannot  be  treated  efficiently  by  measures  short  of  operation,  I  have  obtained 
considerable  success  by  dividing  constricting  bands  and  adhesions,  and  by 
subsequent  careful  attention  to  the  proper  functioning  of  the  bowel.  In  a 
considerable  proportion  of  cases,  and  more  particularly  in  women,  such  means 
are  insufficient,  as  at  the  best  the}"  only  atford  temporary  relief,  since  the 
obstruction  recurs  sooner  or  later. 

"In  my  earliest  cases,  after  the  appendix  had  been  removed  and  the  cecum 
and  flexures  freed  from  adhesions  on  one  or  more  occasions,  with  transitory 
benefit,  I  looked  about  for  some  means  of  relieving  the  patients  of  the  cecal 
pain  from  which  they  sufi^ered  and  for  the  relief  of  which  they  were  readj^  to 
submit  to  any  operation.  Pain  was  the  chief  symptom  of  which  they  com- 
plained. 

"In  the  first  case  I  merely  made  a  lateral  anastomosis  between  the  ileum 
and  sigmoid,  but  the  early  return  of  cecal  pain  obliged  me  to  divide  the  ileum. 
In  several  of  the  cases  in  which  I  had  divided  the  ileum,  after  an  interval  of 
months  the  patients  were  occasionally  annoyed  by  the  presence  of  hard,  dry 
masses  of  fecal  matter  in  the  cecum.  They  produced  no  auto-intoxication, 
but  the  discomfort  arising  from  their  presence  and  from  flatulent  distension 
was  sufficient  to  call  for  the  removal  of  the  large  bowel  as  far  as  the  splenic 
flexure.  These  hard  masses  of  feculent  material  are  not  necessarily  the  result 
of  regurgitation,  but  are  probably  formed  in  the  large  bowel.  A  still  more 
extended  experience  showed  me  that  if  any  portion  of  the  large  bowel  is  left 
above  the  junction  with  the  ileum  it  tends  to  dilate  sooner  or  later.  This  dila- 
tation may  interfere  with  the  satisfactory  evacuation  of  feces,  and  discomfort 
or  pain  may  ensue  because  of  its  distension  by  fecal  matter  or  gas.  Therefore, 
to  overcome  completely  the  constipation  as  well  as  the  septic  absorption,  the 


End  of  ileum ^ 
thru  abd.nair 


;.-'"    Tr*'    ~^-^'^~nasToTnojis 


^rox'iml  end  o^ 
colon  op-'^n'O^' 


Operation  fob  the  Elimination  of  the  Ascending,  Transverse  and  Descending  Colon  for 

THE  Belief  of  Intestinal  Stasis. 

The  ileum  has  been  severed  10  cm.  from  the  cecum  and  the  cecal  end  passed  through  a 
MeBurney  incision,  making  a  permanent  colostomy  at  this  point.  The  sigmoid  has  also  been 
severed  and  the  end  of  the  descending  colon  passed  through  a  similar  MeBurney  incision  on 
the  left  side.  An  end-to-end  anastomosis  was  then  made  between  the  proximal  end  of  the  ileum 
and  distal  end  of  the  sigmoid,  and  a  rectal  drainage  tube  passed  up  into  the  ileum.  The  colon 
can  now  be  flushed  out  through  its  two  colostomy  openings.  By  this  operation  the  patient  is 
relieved  of  the  intestinal  stasis  without  undergoing  the  great  risk  of  a  complete  excision  of  the 
colon. 


314 


GENERAL  SURGERY  OF  THE  ABDOMEN 


Intestinal,  X-Eat. 

Radiogram  after  colon  injection  showing  ptosis  of  transverse  colon,  angulation 
at  splenic  flexure,  incomplete  filling  of  ascending  portion  (adhesion  band)  and 
redundant  sigmoid. 


GENERAL  SURG-ERY  OF  THE  ABDOMEN  315 


Intestinal  X-Eat. 


Eadiogram  of  injected  colon  showing  marked  ptosis   of  colon,  the  entire  large 
bowel  lying  in  the  pelvis. 


316 


GENERAL  SURGERY  OF  THE  ABDOMEN 


Intestinal  X-Ray. 

Eadiogram  of  injected  colon.     Adhesion  causing  constriction  at  A;   greatly  dilated 
transverse  and  ascending  colon,  B;   distended  cecum,  C;  redundant  sigmoid. 


GENERAL  SURGERY  OF  THE  ABDOMEN  317 

large  bowel  should  be  removed  as  far  as  its  junction  with  the  ileum,  which  is 
effected  in  the  upper  part  of  the  rectum  or  in  the  adjacent  sigmoid. 

"Therefore,  when  I  recognize  that  the  mechanics  of  the  intestines  have 
been  altered  to  a  degree  that  cannot  be  rectified  satisfactorily  by  the  division 
of  bands,  etc.,  I  divide  the  ileum  at  a  distance  of  about  five  or  six  inches  from 
the  cecum.  This  can  be  done  rapidly  and  securely  by  encircling  it  by  means 
of  a  catgut  ligature. 

"The  ileum  is  divided  by  the  cautery  immediately  beyond  the  ligature.  The 
stump  is  then  buried  in  the  proximal  bowel  by  means  of  a  purse-string  suture 
which  encircles  the  bowel  and  perforates  its  peritoneal  and  muscular  coats 
about  three-quarters  of  an  inch  above  its  ligatured  extremity,  rendering  the 
closure  absolutely  secure. 

' '  The  acquired  adhesions  and  peritoneum  which  bind  the  cecum  and  ascend- 
ing colon  to  the  abdominal  wall  external  to  them  are  divided,  and  the  bowel 
is  raised  till  the  vessels  which  supply  it  are  exposed.  These  are  grasped  in 
compression  forceps  and  firmly  ligatured.  The  vessels  supplying  the  transverse 
colon  are  similarly  treated,  and  finally  the  descending  colon  and  perhaps  the 
sigmoid  are  removed,  the  upper  limit  of  the  rectum  or  the  lower  part  of  the 
sigmoid  being  occluded  in  the  same  manner  as  the  ileum. 

"Originally  I  had  been  satisfied  to  divide  the  transverse  colon  at  the  splenic 
flexure,  closing  the  distal  portion  in  the  manner  already  described,  but  for  the 
reasons  I  have  given  I  now  remove  the  descending  colon  and  a  portion  or  the 
whole  of  the  sigmoid,  closing  the  large  bowel  at,  or  just  above,  its  junction 
with  the  rectum. 

"The  termination  of  the  ileum  and  the  sigmoid  or  rectum  adjacent  to  it 
are  brought  into  convenient  apposition,  and  a  perfectly  secure  and  reliable 
lateral  anastomosis  is  made  by  means  of  a  double  row  of  continuous  sutures, 
the  inner  row  of  which  perforates  all  the  coats,  while  the  outer  does  not  enter 
the  lumen  of  the  bowel. 

"If  the  surgeon  prefers  it,  the  ileum  and  rectum  may  be  united  end-to-end. 
This  is  the  ideal  way,  since  any  tendency  to  pouching  which  exists  in  the 
case  of  lateral  anastomosis  is  avoided.  The  objections  to  it  are  that  it  is  not 
so  safe  because  of  the  difference  in  the  circumference  of  the  two  pieces  of 
bowel,  the  frequent  very  great  tenuity  of  the  wall  of  the  ileum,  and  the  diffi- 
culty occasionally  met  with  in  dealing  with  the  mesenteric  attachment. 

"Subsequent  dilatation  of  the  ileum  beyond  the  seat  of  lateral  anasto- 
mosis may  be  avoided  by  sewing  down  and  obliterating  the  lumen  of  the  distal 
gut  right  up  to  the  aperture  of  communication  with  the  large  bowel. 

"Finally,  a  fine  gut  ligature  is  passed  through  the  free  incised  margin  of 
the  mesentery  of  the  ileum,  and  then  beneath  the  peritoneum  forming  the  outer 
wall  of  the  meso-rectum.  This,  when  made  tight,  brings  the  rectum  to  the 
middle  line  of  the  pelvis  and  fixes  it  securely  in  that  situation  immediately 
beneath  the  position  occupied  normally  by  the  divided  end  of  the  ileum.  The 
ligature  also  closes  the  interval  between  these  two  mesenteries,  through  which 
a  loop  of  bowel  might  otherwise  pass  and  give  trouble. 

' '  There  are  many  cases  in  which  the  patient  is  unable  to  sustain  the  strain 
of  the  removal  of  the  large  bowel,  but  can  that  of  division  of  the  small  bowel 
and  the  establishment  of  a  connection  between  it  and  the  sigmoid  or  rectum. 
This  operation  relieves  the  patient  of  the  toxemia. 

"Should  the  symptoms  resulting  from  the  distension  of  the  colon  cause 
sufficient  trouble  the  large  bowel  can  be  removed  at  a  later  date  with  much 
less  risk. 

"Again,  there  are  a  number  of  cases  of  extreme  toxemia,  who  have  no 


318 


GENERAL  SURGERY  OF  THE  ABDOMEN 


pain,  and  in  whom  the  division  of  the  ileum  and  its  connection  with  the  end 
of  the  large  bowel  is  sufficient,  since  it  relieves  the  patient  of  all  trouble. 

"The  stomach  is  exposed  and  is  usually  found  to  be  dilated  to  a  varying 
extent.     In  this  condition  the  pylorus  is  hung  up  by  adhesions  to  the  liver 


1.  Showing  Tube  Introduced  Through  the  Eectum  Up  into  Proximal  Sigmoid,  andi 

Placing  of  Catgut  Suture. 

and  gall-bladder.  These  are  freely  divided.  I  have  employed  gold  leaf  to 
obviate  the  re-formation  of  adhesions  with  apparent  advantage.  The  adhe- 
sions tend  to  re-form  since  the  mechanical  factors  determining  their  develop- 
ment continue  to  exist.     When  the  weight  of  the  transverse  colon  has  been 


2.  Showing  Tube  Used  for  Bringing  the  Two  Ends  into  Apposition,  and  First  Eow  op 

Sutures  Placed. 

removed,  during  the  period  of  recumbency  following  on  the  operation,  the 
dilatation  of  the  stomach  usually  disappears  more  or  less  completely.  On 
several  occasions  after  a  varying  interval  from  the  operation  of  resection  of 
the  large  bowel,  the  dilatation  of  the  stomach  has  become  a  feature  of  sufficient 


3.  Showing  Intussusception  Accomplished  and  Outer  Eow  of  Sutures  Placed. 


importance  to  require  its  more  effective  drainage  by  a  gastro-enterostomy. 
This  operation  has  afforded  complete  relief  of  the  gastric  symptoms.  I  have 
seen  cases  of  chronic  intestinal  stasis  in  which  a  gastro-enterostomy  alone  had 
been  done  for  dilatation  of  the  stomach  with  very  distinct  disadvantage  to  the 


GENERAL  SURGERY  OF  THE  ABDOMEN  319 

patient.  The  surgeon  lias  not  recognized  the  sequence  and  he  has  brought 
the  operation  of  gastro-enterostomy  into  disrepute.  Indeed,  I  have  seen  it 
frequently  stated  that  gastro-enterostomy  is  of  no  service  unless  there  be 
obstruction  to  the  pylorus  by  growth  or  cicatrix.  To  attempt  to  relieve 
symptoms  by  performing  a  gastro-enterostomy  in  the  first  instance  in  the 
dilatation  of  the  stomach  that  follows  upon  chronic  intestinal  stasis  is  of  little 
or  no  avail. ' ' 

CARCINOMA  IN  THE  UPPER  PORTION  OF  THE  RECTUM 

If  a  carcinoma  is  located  in  the  upper  portion  of  the  rectum  it  is  often 
impossible  to  approach  it  from  below,  but  it  can  be  removed  with  ease  through 
an  abdominal  incision.  This  operation  is  indicated  only  if  the  tumor  is 
confined  entirely  to  the  intestine,  because  if  the  surrounding  tissues  have 
been  invaded  the  removal  of  the  tumor  would  in  no  way  retard  the  progress 
of  the  disease. 

Technique.  Under  favorable  conditions,  then,  the  following  operation  is 
indicated:  The  patient  is  placed  in  the  exaggerated  Trendelenburg  position. 
An  incision  is  made  through  the  linea  alba  extending  from  the  pubis  to  a  point 
an  inch  below  the  umbilicus.  The  intestines  are  held  away  by  means  of  moist, 
gauze  tampons.  The  sigmoid  flexure  is  then  found  and  grasped  between  two 
pairs  of  long-jawed  pressure  forceps  placed  side  by  side  at  a  sufficient  distance 
above  the  tumor  to  make  sure  that  every  portion  of  the  growth  is  several  inches 
below  the  lower  pair  of  forceps.  The  intestine  is  then  severed  between  these 
two  pairs  of  forceps  and  a  second  incision  is  made  in  the  left  inguinal  region, 
corresponding  to  McBurney's  incision  for  the  removal  of  the  vermiform  appen- 
dix only  upon  the  opposite  side,  care  being  taken  to  separate  the  fibers  of  the 
external  and  internal  oblique  abdominal  muscles,  as  described  in  the  previous 
operation.  A  pair  of  lonsr-jawed  pressure  forceps  is  then  passed  through  this 
opening  and  attached  to  the  upper  segment,  Avhich  is  withdrawn  through  this 
wound  and  carefully  sutured  to  its  edges,  after  a  large  rubber  tube  surround- 
ing a  glass  cylinder  has  been  inserted  in  this  segment  and  fastened  in  place 
by  means  of  a  purse-string  suture.  This  will  permit  the  escape  of  gas  and 
feces  without  any  danger  of  soiling  the  abdominal  wound.  The  pair  of  forceps 
upon  the  lower  segment  is  lifted  toward  the  abdominal  incision  and  the  pos- 
terior attachment  of  the  intestine  below  these  forceps  is  successively  grasped 
by  means  of  pressure  forceps,  and  as  the  attachment  is  grasped  the  intestine 
is  cut  loose.  In  this  manner  the  entire  intestine  can  be  loosened  without  the 
slightest  danger  of  hemorrhage.  If  the  diseased  portion  is  not  extensive  two 
other  pairs  of  pressure  forceps  are  placed  parallel  to  each  other  at  a  sufficient 
distance  below  the  tumor  to  insure  its  complete  removal.  The  intestine  is  cut 
off  between  these  two  forceps  and  the  tumor  removed,  together  with  the  for- 
ceps above  and  below  it.  A  purse-string  stitch  is  applied  around  the  lower 
segment,  and  the  edges  caught  by  means  of  the  pressure  forceps  are  inverted. 
Then  the  entire  abraded  surface  is  covered  with  peritoneum  and  the  ab- 
dominal wound  closed.  Occasionally  the  sigmoid  flexure  is  so  long  and  its 
attachments  so  loose  that  it  is  possible  to  withdraw  the  upper  segment  through 
the  lower  segment  and  treat  according  to  the  method  introduced  by  Gibson, 
which  has  already  been  fully  described. 

At  this  point  we  wish  to  emphasize  the  fact  that  it  is  most  .important  to 
make  a  free  excision  of  these  tumors,  and  that  in  no  case  should  one  make 
a  less  thorough  operation  for  the  sake  of  maintaining  the  natural  instead  of 
the  artificial  anus. 


320 


GENERAL  SURGERY  OF  THE  ABDOMEN 


Excision  of  Cecum  and  Ascending  Colon  (A). 

(As  described  by  Dr.  W.  J.  Mayo,  Journal  A.  M.  A.,  August  8,  1914.) 
Fig.  A  shows  the  manner  of  exposing  the  blood-vessels  supplying  the  cecum,  also  the  ureter 
and  the  loop  of  duodenum,  which  can  easily  be  injured  during  the  operation  unless  the  surgeon 's 
attention  is  directed  toward  the  proximity  of  this  structure  to  the  field  of  operation. 


GENERAL  SURGERY  OF  THE  ABDOMEN 


321 


Excision  of  Cucuii  (B). 

Fig.  B  shoTvs  the  operation  completed  with  the  exception  of  the  loTver  end  of  the  peritoneal 
defect,  which  is  being  closed  with  a  continuous  catgut  suture.  The  liver,  gall  bladder,  stomach, 
lower  end  of  the  right  kidney  and  duodenum  are  in  view,  also  a  portion  of  the  sigmoid  Hexure 
of  the  colon  below  the  portion  of  the  ileum,  which  has  been  united  with  the  transverse  colon 
by  an  end-to-side  anastomosis,  and  the  closed  end  of  the  resected  transverse  colon  Ihese 
structures,  together  with  the  omentum,  have  been  drawn  to  the  left  m  order  to  show  the 
abdominal  aorta  and  the  inferior  vena  cava. 


21 


322  GENERAL  SURGERY  OF  THE  ABDOMEN 

INTESTINAL  FISTULA 

Causes  and  incidence.  Intestinal  fistulse  at  the  present  time  occur  most 
frequently  after  operations  performed  for  the  relief  of  acute  appendicitis 
complicated  by  the  formation  of  extensive  abscesses.  The  fistulte  are  more 
common  in  cases  in  which  the  appendix  itself  has  not  been  removed,  or  in  which 
the  appendix  has  been  removed  at  an  inappropriate  time  or  with  extreme 
manipulations.  The  condition  also  occurs  after  other  operations  in  which  the 
intestinal  wall  has  been  injured  either  by  disease  or  by  the  operation,  or  by 
the  drainage  tube  which  was  applied  after  operation.  It  is  more  common 
after  operations  which  have  been  performed  for  the  relief  of  inflammatory 
conditions,  such  as  pyosalpinx.  It  also  occurs  after  operations  for  strangu- 
lated hernia  and  after  those  for  the  resection  of  any  portion  of  the  intestinal 
tract.  After  operations  for  the  relief  of  tubercular  peritonitis,  in  which  the 
adhesions  between  loops  of  intestines  have  been  separated,  intestinal  tistulas 
frequently  occur;  they  also  follow  direct  injury  to  the  intestinal  tract. 

Spontaneous  cure.  A  considerable  proportion  of  intestinal  fistulas  will 
heal  if  absolute  rest  is  secured  as  nearly  as  possible.  This  may  be  accomplished 
most  readily  by  first  emptying  the  alimentary  canal  thoroughly  by  means  of 
large,  repeated  doses  of  castor  oil,  which  will  remove  not  only  the  food,  but 
also  all  mucus  contained  in  the  canal.  The  fistulas  should  be  thoroughly 
cleansed  by  irrigation.  This  should  be  followed  by  feeding  the  patient  exclu- 
sively by  means  of  nutrient  enemata.  In  this  manner  the  intestinal  canal  may 
be  kept  relatively  empty  for  a  number  of  days,  and  in  the  meantime  the  open- 
ings in  the  intestine  are  likely  to  decrease  in  size  unless  there  is  a  marked 
eversion  of  the  mucous  membrane.  If  this  condition  is  present  nothing  but  a 
radical  operation  will  bring  relief.  The  same  is  true  if  there  is  a  stricture  or 
narrowing  of  the  intestinal  canal  distal  to  the  fistula.  Occasionally  this  will 
prevent  the  healing  of  an  intestinal  fistula  which  would  otherwise  respond 
readily  to  treatment. 

Operative  technique.  It  is  usually  wise  to  postpone  the  operation  until 
the  course  above  described  has  been  thoroughlv  tried,  because  one  will  fre- 
quently succeed  by  the  simpler  method  even  after  the  fistula  has  existed  for 
a  considerable  time,  and  this  is  especially  true  of  fistulre  in  portions  of  the  colon 
where  the  bowel  is  covered  with  peritoneum. 

The  incision  through  the  abdominal  wall  should  be  made  at  some  distance 
from  the  fistula  so  as  to  avoid  the  adhesions  which  one  is  sure  to  encounter 
at  the  point  where  the  abdominal  wall  is  penetrated  by  the  fistula.  The 
amount  of  traumatism  necessary  for  performing  the  operation  required  is  very 
much  reduced  if  this  precaution  is  taken,  because  the  conditions  may  be 
determined  much  more  perfectly  if  the  abdominal  cavity  is  opened  at  a  point 
quite  away  from  these  adhesions.  The  incision  should  be  sufficiently  long 
to  permit  of  performing  the  entire  operation  in  full  sight. 

After  the  abdominal  cavity  has  been  opened  all  of  the  intra-abdominal 
organs  should  be  tamponed  away  from  the  portion  of  the  intestines  involved, 
then  these  should  be  loosened  from  the  abdominal  wall  and  carefully  brought 
out  so  that  all  abrasions  upon  their  surfaces  may  be  carefully  repaired.  At- 
tention is  then  given  to  the  fistula  itself.  In  cases  following  appendicitis 
operation  the  fistula  most  frequentlv  enters  the  appendix  at  the  point  at  which 
that  organ  was  perforated  during  the  acute  attack.  All  that  needs  to  be  done 
in  such  instance  is  to  remove  the  entire  appendix  after  the  methods  described 
heretofore.  In  these  cases  the  method  of  sepai"ating  the  appendix  first  from 
its  cecal  end  and  then  dissecting  it  out  distally  is  especially  useful.  It  may 
be  dissected  out  together  with  the  fistula.  The  abraded  surfaces  upon  the 
iptestines  which  have  been  adhereiqit  must  be  carefully  covered  with  peritoneum, 


GENERAL  SURGERY  OF  THE  ABDOMEN 


323 


It  is  usually  well  to  pass  a  drain  through  the  opening  in  the  abdominal  wall 
through  which  the  fistula  extended  down  to  the  seat  of  injury  in  the  intestine, 
and  then  to  completely  close  the  new  opening  in  the  abdominal  wall.  If  the 
fistula  is  in  the  cecum  it  is  usually  not  difficult  to  close  it  by  means  of  sutures 
if  the  following  points  are  borne  in  mind : 

1st.     The  tissues  to  be  sutured  must  not  be  cicatricial  in  character. 
^      2nd.     The  sutures  must  be  applied  with  great  accuracy  so  as  to  have  a 
perfect  coaptation  of  surfaces. 


A.Co\ltA    VtvcJ   4 


A.Colica  dt^  d 


A.lUo  tolioaiL  _ 


Carcinoma  of  the  Cecum. 
Dotted  lines  indicate  points  of  resection. 

3d.     The  sutures  must  not  grasp  too  large  an  amount  of  tissue. 

4th.  The  entire  line  of  sutures  when  completed  must  be  covered  with 
healthy  peritoneum  or  with  a  piece  of  omentum. 

A  drain  should  be  placed  down  to  the  point  of  suture  as  described  above. 

In  fistulas  of  the  small  intestines  it  is  usually  advisable  to  make  a  resec- 
tion of  a  considerable  portion  of  the  bowel,  in  fact,  a  sufficient  amount  should 
be  removed  to  make  the  anastomosis  between  the  ends  in  entirely  healthy 
tissue.  This  can  then  be  accomplished  by  means  of  the  Murphy  button,  as 
described  before;  or  by  means  of  the  continuous  or  interrupted  intestinal 
suture,  also  described ;  or  the  ends  of  the  intestine  may  be  closed  and  a  lateral 
anastomosis  may  be  made  after  the  method  already  outlined,  which  is  the 
safest,  as  a  rule.     In  any  event  the  important  point  to  be  borne  in  mind  is 


324  GENERAL  SURGERY  OF  THE  ABDOMEN 

that  the  operation  must  be  done  entirely  in  healthy  tissue.  The  loss  of  a  num- 
ber of  feet  of  small  intestine  is  of  practically  no  importance  to  the  patient, 
but  if  too  little  is  taken  away  for  the  sake  of  saving  a  small  portion  of  intes- 
tine a  subsequent  perforation  is  liable  to  occur. 

Fistulge  following  operations  for  the  relief  of  tubercular  peritonitis  can 
usually  be  healed  only  if  the  tuberculosis  affects  but  a  relatively  small  por- 
tion of  the  intestine  which  can  be  removed  in  toto.  In  this  case  the  same 
conditions  obtain  which  have  just  been  described.  If  the  tuberculosis  is  not 
relatively  circumscribed  then  these  fistula  can  virtually  never  be  cured. 

Occasionally  an  intestinal  fistula  is  complicated  by  such  extensive  adhe- 
sions that  it  seems  unsafe  to  loosen  them,  and  it  then  may  become  necessary 
to  make  a  lateral  anastomosis  between  the  intestine  going  toward  the  fistula 
and  that  coming  from  it  in  order  to  short-circuit  the  gut  at  this  point.  It  is 
best  to  pass  a  silk-purse-string  suture  about  the  portion  of  bowel  to  be  elimi- 
nated just  beyond  the  anastomosis,  in  order  to  prevent  intestinal  contents  from 
entering  this  portion.  The  suture  should  be  applied  subperitoneally  and  tied 
just  tightly  enough  to  accomplish  this  end  without  causing  pressure  necrosis. 

INTUSSUSCEPTION 

This  is  encountered  usually  in  very  small  children  although  it  occurs  occa- 
sionally in  children  ten  years  of  age  or  even  older,  and  it  may  happen  in  the 
adult,  but  so  rarely  that  we  have  never  seen  such  an  instance.  Our  eldest 
patient  was  not  more  than  twelve  years  of  age,  while  we  have  treated  many 
children  between  one  and  four  years  old. 

Typical  iCase.  Tlie  child  is  sixteen  months  of  age  and  had  been  perfectly  well  until 
six  hours  ago  when  she  suddenly  began  to  complain  of  severe  colicky  pain  in  the  abdomen. 
She  desired  to  evacuate  her  bowels  but  was  unsuccessful.  Half  an  hour  later  a  second  attempt 
was  unsuccessful  and  an  enema  which  was  given  in  the  hope  of  relieving  the  condition  came 
away  clear,  although  a  slight  amount  of  mucus  was  expelled  directly  after.  From  this  time 
on  the  patient  has  had  repeated  attacks  of  pain,  very  severe,  causing  the  child  to  cry  out 
and  draw  its  thighs  upon  its  abdomen. 

The  family  physician  gave  an  enema  and  a  mild  sedative  and  advised  the  use  of  calomel 
later  on  in  case  relief  should  not  come.  A  second  physician  was  called  and  applied  hot 
fomentations  to  the  abdomen  and  recommended  consulting  a  surgeon  later.  The  pain  becom- 
ing constantly  more  severe  and  the  parents  having  had  exiierience  the  previous  year  with 
an  acute  perforative  appendicitis  in  a  child  two  years  older,  the  consultation  was  arranged 
for  jiromptly. 

Present  condition.  The  child  being  undressed  we  find  a  well-nourished, 
perfectly  healthy  appearance,  with  excellent  color  and  well-formed  body. 
Lungs  and  heart  are  normal.  While  inspecting  the  abdomen  a  bulging  appears 
opposite  the  middle  of  the  right  rectus  abdominis  muscle,  at  the  same  time  the 
child  draws  its  thighs  up  over  the  abdomen  and  begins  to  cry,  evidently 
because  of  severe  intra-abdominal  pain. 

All  of  these  symptoms  subside  in  about  two  minutes.  Palpation  of  the 
abdomen  reveals  a  hard,  sausage-like  body  to  the  right  and  a  little  above  the 
umbilicus  in  the  region  normally  occupied  by  the  hepatic  flexure  of  the  colon. 
The  abdominal  muscles  over  this  mass  are  somewhat  tense.  Nothing  else 
abnormal  can  be  discovered.  Some  mucus  which  has  been  expelled  is  slightly 
streaked  with  blood.  Upon  again  questioning  the  nurse  the  fact  that  the  child 
fell  from  a  foot-stool  upon  the  carpet  early  in  the  afternoon  was  elicited,  but 
as  the  child  had  arisen  at  once  and  had  not  complained  the  matter  had  not 
impressed  itself  upon  the  maid  until  she  was  questioned  specifically.  The  child 
had  taken  a  little  water  since  the  time  of  the  fall  but  no  food. 

The  second  physician  had  made  a  diagnosis  of  intussusception  which  we 
confirmed  at  once  upon  making  the  examination  just  described.    The  child  was 


GENERAL  SURGERY  OF  THE  ABDOMEN  325 

brought  to  the  hospital  and  we  "U'ill  make  an  abdominal  section  without  any 
delay,  because  all  of  these  cases  operated  within  the  first  twenty-four  hours 
after  the  beginning  of  the  attack  have  made  a  perfect  recovery,  while  those  in 
whom  the  operation  had  been  delayed  longer  showed  much  less  favorable 
results. 

The  patient  will  be  immediately  anesthetized  with  ether,  then  the  skin  cov- 
ering the  abdomen  will  be  disinfected  in  usual  manner  and  then  we  will  split 
the  right  rectus  abdominis  muscle  longitudinally  at  a  point  opposite  the 
umbilicus  by  an  incision  fifteen  cm.  long,  dividing  the  muscle  as  nearly  as 
possible  into  halves.  It  is  best  to  make  the  incision  sufficiently  long  to  prevent 
trauma  to  the  intestine  during  the  subsequent  manipulations. 

The  cecum,  a  portion  of  the  ileum  and  the  vermiform  appendix  have  been 
telescoped  into  the  transverse  colon.  Seeing  this  mass  before  you  there  is 
temptation  to  seize  the  ileum  and  make  traction  upon  it  for  the  purpose  of 
reducing  the  intussusception.  Experience  has  shown,  however,  that  such  a 
course  is  not  proper,  because  it  seems  to  wedge  the  inner  intestine  more  tightly 
to  the  outer  one ;  while  by  pressing  upon  the  outer  surface  of  the  colon  just 
beyond  the  point  to  which  the  inner  gut  reaches  the  latter  may  be  readily 
pushed  back  until  the  whole  length  of  intestine  is  again  free.  A  careful  inspec- 
tion of  the  cecum,  transverse  colon  and  ileum  shows  that  no  necrosis  and  no 
abrasion  has  taken  place.  Had  the  intussusception  remained  for  twenty-four 
hours  or  longer  some  points  of  gangrene  and  some  areas  of  abrasion  would 
surely  be  discovered.  Still  later  a  large  portion  of  the  intestine  becomes  gan- 
grenous. Occasionally  such  a  gangrenous  intestine  will  slough  away  entirely 
and  be  expelled  through  the  rectum,  the  two  portions  beyond  this  segment 
uniting  spontaneously,  but  much  more  frequently  the  condition  results  in  a 
fatal  peritonitis. 

Upon  inspecting  the  vermiform  appendix  we  find  that  it  is  fourteen  cm. 
long  and  that  it  forms  a  constricting  band  around  the  ileum,  just  outside  of  the 
ileo-cecal  junction.  It  is  likely  that  when  the  child  had  its  fall  the  appendix 
was  thrown  around  the  ileum  in  this  abnormal  position  and  that  the  constric- 
tion caused  by  the  appendix  at  this  point  was  the  exciting  cause  which  produced 
the  invagination. 

"We  will  remove  the  appendix  in  the  usual  manner  and  close  the  abdominal 
wound. 

During  the  entire  operation  there  has  been  but  very  little  manipulation  of 
the  intra-abdominal  organs,  and  it  seems  reasonable  to  expect  that  this  patient 
will  recover  without  shock  or  sepsis. 

After-treatment.  The  patient  will  be  kept  quiet,  she  will  be  nourished  for 
four  days  by  nutrient  enemata,  then  broth  will  be  given  by  mouth.  Small 
cleansing  enemata  will  be  employed  to  evacuate  the  bowel.  No  cathartics  will 
be  allowed  for  one  month.  Only  such  food  will  be  given  as  can  be  easily 
digested  without  producing  much  residue. 

In  cases  that  come  under  surgical  treatment  later,  after  the  intestine  has 
become  gangrenous,  it  is  best  to  excise  all  of  the  bowel  involved  in  the  intus- 
susception, after  the  method  described  for  excision  of  the  colon  with  a  part  of 
the  ileum. 

Frequently  by  first  making  an  attempt  at  reduction  of  the  intussusception 
in  late  cases  the  peritoneum  is  so  severely  infected  that  the  patient  dies  of 
diffuse  peritonitis,  while  he  would  surely  have  recovered  had  these  useless 
manipulations  been  omitted. 

In  making  this  excision  it  is  well  to  remember  that  it  is  even  more  likely 
to  injure  the  duodenum  in  this  operation  than  in  the  simple  excision  of  the 
ascending  colon,  but  if  the  surgeon's  attention  has  been  directed  to  the  fact  it 
is  not  difficult  to  avoid  this  complication. 


326  GENERAL  SURGERY  OF  THE  ABDOMEN 

VOLVULUS 

Another  common  condition,  which,  like  intussusception,  is  characterized  by 
intestinal  obstruction,  consists  of  a  twisting  of  the  small  intestine,  the  sigmoid 
flexure  of  the  colon,  or,  much  more  rarely,  the  transverse  colon  upon  its  mesen- 
tery, thus  at  once  obstructing  the  passage  and  destroying  the  circulation.  The 
twisting  of  the  mesentery  gives  rise  to  severe  pain. 

The  closure  of  the  intestine  causes  nausea  and  vomiting,  the  vomitus  con- 
sisting at  first  of  stomach  contents,  then  mucus  and  bile,  and  later  more  or  less 
decomposed  intestinal  contents. 

The  vomiting  appears  early  when  the  volvulus  occurs  in  the  jejunum,  later 
when  in  the  ileum,  and  quite  late  when  in  the  colon. 

The  condition  is  frequently  preceded  by  a  slight  fall  or  by  excessive  lifting 
or  straining.  Occasionally  it  may  be  mistaken  for  an  acute  gastric  disturb- 
ance, because  of  taking  some  indigestible  food,  and  a  few  times  we  have 
observed  patients  who  imagined  that  they  had  taken  spoiled  food  and  that 
they  were  suffering  from  ptomaine  poisoning. 

Several  times  we  have  had  patients  sent  to  the  hospital  with  a  diagnosis  of 
volvulus  in  whom  we  found  the  obstruction  due  to  a  small  hernia  which  had 
not  previously  been  recognized.  The  fact  that  the  condition  had  come  on 
suddenly  after  a  slight  exertion  had  given  rise  to  the  mistaken  diagnosis.  In 
another  case  the  hernia  was  so  slight  that  it  was  not  discovered  until  it  was 
located  after  the  abdomen  had  been  opened,  when  a  small  portion  of  one  side 
of  the  small  intestine  was  found  caught  in  the  femoral  ring,  the  obstruction 
being  due  to  the  kinking  of  the  intestine. 

Although  it  is  not  always  possible  to  make  a  differential  diagnosis  between 
volvulus  and  acute  intestinal  obstruction  from  other  causes  it  is  possible  to 
determine  the  presence  of  a  mechanical  obstruction  to  the  intestines,  and  it 
does  not  matter  what  may  be  the  cause  of  this  condition  as  the  indication  for 
treatment  is  always  the  same. 

ACUTE  MECHANICAL  OBSTRUCTION  OF  THE  INTESTINE 

Before  speaking  of  the  special  treatment  for  volvulus  it  may  be  well  to 
discuss  the  treatment  of  acute  intestinal  obstruction,  which  applies  to  this 
condition  without  regard  to  the  mechanical  condition  which  gives  rise  to 
obstruction  in  any  given  case. 

A  statement  which  should  be  repeated  many  times  and  always  regarded 
when  any  form  of  intestinal  obstruction  is  considered,  and  even  when  there 
is  the  slightest  suspicion  of  the  possibility  of  the  existence  of  intestinal  obstruc- 
tion in  any  given  case,  is  that  it  is  absolutely  unpardonable  to  give  either 
cathartics  or  any  form  of  nourishment  by  mouth.  In  our  experience  the 
mortality  has  been  ten  times  higher  in  patients  who  had  been  given  cathartics 
before  coming  into  the  hospital  suffering  from  intestinal  obstruction,  than  in 
those  who  had  received  none. 

It  is  so  absolutely  clear  that  if  no  food  be  administered  by  mouth  any  case 
in  which  there  is  no  mechanical  obstruction  of  the  bowels  does  not  need  a 
cathartic  because  the  bowels  will  move  spontaneously  if  given  time  and 
proctoclysis  by  the  continuous  drop  method,  while  if  mechanical  obstruction 
is  present  the  giving  of  cathartics  will  almost  certainly  kill  the  patient.  In 
other  words  in  order  to  prove  that  a  certain  number  of  patients  do  not  have  a 
mechanical  obstruction  of  the  intestines  one  takes  the  risk,  hy  using  cathartics, 


GENERAL  SURGERY  OF  THE  ABDOMEN  327 

of  destroying  the  lives  of  almost  all  of  those  who  are  actually  suffering  from 
this  condition. 

The  reason  "vvhy  it  is  so  dangerous  to  give  cathartics  in  these  cases  is  because 
they  enormously  increase  the  pressure  above  the  point  of  obstruction,  and  con- 
sequently the  intestine  is  made  more  permeable  to  micro-organisms  in  its  lumen 
and  the  increased  pressure  hastens  the  occurrence  of  gangrene  of  the  intestine 
at  the  point  of  obstruction. 

As  harmful  as  is  the  giving  of  food  and  cathartics  in  these  cases,  so  equally 
beneficial  is  the  opposite  form  of  treatment  by  means  of  repeated  gastric 
lavage,  which  removes  a  great  amount  of  poisonous  material  from  the  ali- 
mentary canal  and  permits  the  intestines  and  the  stomach  to  contract.  It  also 
prevents  the  occurrence  of  inspiration  pneumonia  caused  by  the  presence  of 
fetid  intestinal  contents  during  the  operation. 

AYhen  in  doubt  in  these  cases  a  competent  surgeon  should  operate,  although 
by  carefully  taking  the  history  and  examining  these  patients  an  experienced 
surgeon  can  almost  always  make  a  positive  diagnosis. 

On  the  other  hand  an  inexperienced  surgeon  who  is  in  doubt  should  con- 
tinue denying  absolutely  everything  by  mouth,  should  employ  gastric  lavage 
and  administer  normal  salt  solution  by  rectum  by  the  continuous  drop  method 
until  the  patient  can  be  gotten  into  the  hands  of  a  competent  surgeon. 

Operative  technique.  Y^hen  it  is  possible  to  locate  the  twisted  loop  of 
intestine  by  the  bulging  of  some  portion  of  the  abdominal  wall,  or  by  ausculta- 
tion (the  intestinal  fluid  moving  up  to  a  given  point  and  stopping  at  such 
point),  or  by  the  accurate  location  of  pain  or  tenderness,  it  is  well  to  make  the 
incision  either  in  the  median  line  or  by  splitting  either  rectus  abdominis  muscle 
longitudinally  directly  over  the  affected  part. 

Should  the  location  or  the  character  of  the  obstruction,  or  both,  not  be 
positively  demonstrated  before  the  abdomen  is  opened  it  is  best  to  make  a 
median  incision  if  the  appendix,  the  gall  bladder  or  the  duodenum  are  prob- 
ably not  the  seat  of  the  trouble ;  otherwise  an  incision  splitting  the  right  rectus 
abdominis  muscle  probably  gives  the  best  approach  to  the  diseased  part 
because  the  location  of  this  condition  is  twice  as  frequent  in  the  right  as  in  the 
left  half  of  the  abdominal  cavity. 

If  the  intestines  are  greatly  dilated  and  the  patient  is  in  a  fair  condition 
the  gas  and  feces  should  be  first  evacuated  by  emptying  a  small  portion  of  the 
most  prominent  loop  of  the  intestine  by  squeezing  the  contents  in  either  direc- 
tion, then  having  an  assistant  hold  this  empty  portion  between  the  finger  and 
thumb  of  each  hand,  thus  preventing  its  refilling.  A  circular  silk  suture  is 
then  applied  at  a  point  farthest  away  from  the  mesenteric  attachment  of  the 
intestine,  then  a  longitudinal  slit  is  made  into  the  lumen  of  the  intestine  two 
cm.  long.  A  glass  tube  two  cm.  in  diameter,  with  smooth  ends,  and  sixty  cm. 
long  is  inserted  into  this  opening  and  the  edges  of  the  wound  are  inverted  and 
the  suture  is  tied  in  a  loop  so  that  it  can  be  untied  later  on.  Then  the  assistant 
relinquishes  his  grasp  upon  the  intestine  and  its  contents  are  permitted  to  pass 
out  through  the  glass  tube.  It  is  usually  impossible  to  push  this  tube  into  the 
intestines  as  demonstrated  experimentally  by  Monks,  but  the  intestine  can  be 
threaded  upon  the  tube  successively  until  all  of  the  gas  and  feces  have  escaped. 
The  intestine  is  filled  and  emptied  several  times  with  normal  salt  solution  at 
100  to  105  degrees  F.  Then  the  tube  is  withdrawn  slowly  and  this  portion  of 
the  intestine  is  again  grasped  by  the  assistant  in  order  to  prevent  its  refilling 
and  the  glass  tube  is  threaded  into  the  opposite  end,  which  is  emptied  and 
washed  in  the  same  manner.     Then  the  tube  is  withdrawn  and  the  wound  in 


328  GENERAL  SURGERY  OF  THE  ABDOMEN 

the  intestinal  wall  closed,  an  assistant  compressing  the  bowel  at  either  side  to 
prevent  leakage.  It  is  remarkable  how  quickly  the  intestine  takes  on  a  nor- 
mal appearance  under  this  treatment,  and  how  well  these  patients  bear  the 
operation. 

After  the  above  procedures  it  is  possible  to  locate  the  volvulus,  because 
this  will  be  the  only  portion  of  the  intestine  that  remains  distended.  If  the 
intestine  is  gangrenous  or  if  the  mesenteric  vessels  are  thrombosed  its  excision 
according  to  the  methods  already  described  is  indicated.  If  the  volvulus  has 
not  so  resulted  then  the  intestine  must  be  untwisted  and  if  there  are  any  adhe- 
sions they  must  be  clamped,  cut  and  ligated.  If  the  intestine  contained  in  the 
volvulus  is  of  considerable  length  and  not  gangrenous  it  is  well  to  leave  the 
glass  tube  in  place  and  to  evacuate  the  gas  and  fluid  contained  in  this  loop 
before  the  intestine  is  closed.  If  the  volvulus  includes  the  sigmoid  flexure  or 
the  descending  colon  it  is  well  to  pass  a  rubber  tube  up  through  the  rectum 
and  just  beyond  the  loop  involved  in  order  to  secure  drainage  and  to  keep 
the  loop  in  position  until  it  has  been  restored  from  the  effects  of  the  torsion. 
The  tube  should  be  composed  of  fairlj^  pliable  rubber  to  prevent  injury  from 
pressure.  It  is  well  to  have  the  tube  split  longitudinally  to  facilitate  its 
acting  as  a  drain. 

Should  the  patient's  condition  be  very  bad  it  may  be  best  simply  to  make 
an  enterostomy  by  bringing  up  a  distended  loop,  attaching  it  to  the  parietal 
peritoneum,  then  finding  the  volvulus,  untwisting  it,  and  leaving  it  in  place. 
This  operation  in  volvulus  is  so  seldom  followed  by  recovery  that  in  almost 
every  case  the  method  described  before  is  preferable. 

ACUTE  INTESTINAL  OBSTRUCTION  DUE  TO  CONSTRICTING  BANDS 

OF  ADHESIONS 

Here  there  is  usually  a  history  of  a  previous  operation  or  of  peritonitis 
from  any  cause.  In  all  other  details  the  history  and  the  clinical  symptoms 
are  the  same  as  in  volvulus. 

The  treatment  is  the  same,  with  the  exception  that  the  location  of  the 
constricting  band  is  usually  in  the  vicinity  of  the  former  operation,  or  the 
former  peritonitis  the  origin  of  which  is  more  commonly  the  appendix  or  the 
Fallopian  tube,  than  from  any  other  points  in  the  abdominal  cavity,  although 
we  have  seen  several  cases  in  which  the  band  represented  a  remnant  of  the 
omphalomesenteric  duct. 

ACUTE  OBSTRUCTION  DUE  TO  KINKING  OF  INTESTINES 

This  condition  can  but  rarely  be  differentiated  before  the  operation  from 
that  just  described  as  its  origin  and  entire  history  are  the  same,  and  the  treat- 
ment is  identical.  The  attacks  are  usually  somewhat  less  acute  and  less  violent 
and  the  obstruction  is  frequently  not  quite  complete. 

INTESTINAL  OBSTRUCTION  FOLLOWING  ABDOMINAL  OPERATIONS 

During  the  early  days  of  abdominal  surgery  intestinal  obstruction  more  or 
less  complete  in  character  occurred  in  a  large  proportion  of  cases.  This 
resulted  in  a  number  of  forms  of  treatment  for  this  condition.  It  was  found, 
however,  within  a  few  years  that  post-operative  intestinal  obstruction  is  almost 
always  due  to  errors  in  judgment,  or  errors  in  preparation  of  patients  before 


GENEEAL  SURGERY  OF  THE  ABDOMEN 


329 


operation,  or  in  surgical  technique,  or  in  after-treatment,  and  that  by  eliminat- 
ing these  errors  it  is  possible  to  eliminate  post-operative  obstruction  almost 
entirely. 


Intestinal  Obstruction  Due  to  Spasmodic  Contraction  of  Ileum. 

(We  are  indebted  to  Dr.  D.  -N.  Eisendrath  for  the  drawing,  which  was  made  from  one  of 

his  cases. 

Intestinal  obstruction  may  be  complete  as  a  result  of  a  contraction  of  a  loop  of  small 
intestine.  This  contraction  occurs  in  connection  with  acute  appendicitis  and  also  with  pelvic 
infection  and  infection  of  the  gall  bladder. 

In  all  of  these  conditions,  however,  the  obstruction  subsides  if  gastric  lavage  is  employed 
and  if  neither  food  nor  cathartics  are  given  by  mouth,  while  the  patient  is  supported  by  the 
use  of  exclusive  rectal  feeding  and  normal  salt  solution  by  rectum  or  subcutaneously.  Cathartics 
and  food  given  by  mouth  seem  to  increase  the  obstruction. 

Errors  in  preparation.  Patients  undergoing  abdominal  operations  without 
having  the  intestinal  canal  thoroughly  emptied  are  likely  to  develop  a  great 
amount  of  gaseous  distension  of  the  stomach  and  small  intestine,  and  this  in 
turn  is  likely  to  result  in  kinking  of  the  intestine  which  will  cause  a  more 
or  less  complete  obstruction.  By  giving  two  ounces  of  castor  oil  in  the  foam 
of  beer  or  malt  extract  on  the  day  previous  to  the  operation,  and  then  giving 
the  patient  no  food  with  the  exception  of  broth  until  the  operation  has  been 
performed,  post-operative  obstruction  can  be  eliminated.  Of  course,  this  pre- 
paratory treatment  should  never  be  given  in  patients  suffering  from  peritonitis 
or  from  mechanical  obstruction  of  the  intestines. 

Errors  in  technique.    Rough  or  careless  handling  of  the  intestines  during 


330  GENERAL  SURGERY  OF  THE  ABDOMEN 

the  operation,  or  exposure  of  the  intestines  to  the  air,  which  is  more  likely  to 
occur  if  the  intestines  are  not  properly  emptied  before  the  operation  will  result, 
in  many  cases,  in  the  post-operative  obstruction  under  discussion.  This  is 
especially  true  if  the  intestines  and  omentum  are  not  placed  in  their  normal 
position  after  the  operation  is  completed,  and  more  especially  if  some  loops 
of  the  small  intestine  are  permitted  to  become  lodged  in  the  pelvic  cavity  at 
the  conclusion  of  the  operation.  The  latter  cavity  should  be  occupied  by  the 
rectum,  sigmoid  flexure  and  omentum,  particularly  in  operations  upon  the 
female,  because  if  the  small  intestine  becomes  lodged  in  the  cul-de-sac  of 
Douglas  it  is  likely  to  cause  bowel  obstruction. 

Errors  in  post-operative  treatment.  The  administration  of  opium,  food 
and  cathartics  in  a  patient  who  has  undergone  a  severe  intra-abdominal  opera- 
tion is  likely  to  produce  intestinal  obstruction.  If  concentrated,  predigested 
foods  and  normal  salt  solution  are  administered  by  rectum  instead,  then  in 
similar  patients  intestinal  obstruction  will  not  result.  One  of  the  most  im- 
portant prophylactic  measures  in  post-operative  treatment  in  patients  that  have 
undergone  abdominal  section  consists  in  performing  gastric  lavage  in  every 
case  in  which  there  is  gaseous  distension  of  the  stomach  or  intestines  follow- 
ing operation.  This  may  be  repeated  from  one  to  three  times.  In  the  mean- 
time the  patient  should  be  confined  to  exclusive  rectal  feeding  and  to  the  use 
of  normal  salt  solution  by  the  drop  method.  Even  in  cases  in  which  there 
is  complete  obstruction  a  few  days  following  abdominal  operation,  the  obstruc- 
tion will  practically  always  subside  if  this  form  of  treatment  is  instituted  at 
once.  Under  no  condition  should  cathartics  or  anything  else  be  given  b}^  mouth 
in  any  case  in  which  there  are  symptoms  of  post-operative  intestinal  obstruction. 

HERNIA 

General  considerations.  The  most  common  anatomical  varieties  of  hernia, 
in  order  of  their  frequency  are :  1.  Inguinal.  2.  Umbilical.  3.  Femoral.  4. 
Ventral.    5.  Hernia  of  the  linea  alba. 

Among  the  rarer  forms  are :  ischiatic,  pelvic,  obturator,  lumbar,  diaphrag- 
matic, and  the  various  forms  of  retro-peritoneal  hernia,  as  retrocecal,  duodenal, 
and  hernia  through  the  foramen  of  Winslow. 

Clinically  hernias  are  classified  as  reducible,  irreducible,  inflamed  and 
strangulated. 

Reducible  hernia  is  by  far  the  most  common  of  all  varieties.  In  this  form 
the  hernial  contents  may  be  returned  into  the  abdominal  cavity  spontaneously, 
or  when  the  patient  assumes  the  recumbent  position,  or  by  manipulation  by 
the  patient  or  physician. 

In  the  early  stages  of  development  practically  all  hernias  are  reducible. 
Later  on,  from  the  constant  irritation,  in  a  considerable  proportion  of  cases, 
the  hernial  contents  become  adherent  to  the  sac,  making  it  impossible  to  efl^ect 
a  complete  reduction.  This  is  especially  apt  to  happen  in  cases  of  umbilical 
hernia. 

In  other  instances  the  hernial  sac  is  large  and  the  neck  of  the  sac  is  com- 
paratively small,  so  that  considerable  effort  is  required  to  accomplish  the 
reduction.  In  manj^  cases  in  which  it  seems  almost  impossible  to  replace  the 
hernial  contents  when  the  patient  is  in  the  ordinary  recumbent  position,  reduc- 
tion may  be  accomplished  with  ease  after  placing  the  patient  in  the  Trendel- 
enburg position. 

The  hernial  sac.  With  the  exception  of  some  of  the  rarer  forms  of  hernia, 
such  as  diaphragmatic  and  retroperitoneal,  there  is  one  feature  common  to  all, 
and  that  is  the  sac.  This  sac  is  composed  of  a  layer  of  peritoneum  which  covers 
either  a  portion  or  the  entire  contents  of  the  hernia.    The  sac  is  originally  a 


GENERAL  SURGERY  OF  THE  ABDOMEN  331 

very  thin  membrane,  but  may  undergo  marked  changes  in  cases  of  long  stand- 
ing and  in  those  in  which  an  ill-fitting  truss  has  been  worn  for  a  long  time. 
In  such  the  sac  may  become  markedly  thickened,  very  tough  and  of  leathery 
consistence. 

In  the  congenital  form,  the  hernial  sac  is  a  preformed  pouch  of  peritoneum 
which  remains  empty  until  some  unusual  effort  or  accident  causes  an  increased 
intra-abdominal  pressure,  which  forces  some  of  the  abdominal  contents  into 
this  pouch. 

In  the  acquired  variety  the  parietal  peritoneum  is  forced  by  intra-abdom- 
inal pressure  through  some  congenital  defect  in  the  abdominal  wall. 

In  oblique  inguinal  hernia  the  sac  always  bears  a  certain  relation  to  the 
spermatic  cord.  It  is  always  found  in  a  position  anterior  to  the  cord  and  the 
spermatic  vessels,  and  is  surrounded,  together  with  the  latter,  by  the  thin  layer 
of  infundibuliform  fascia.  In  inguinal  hernia  in  the  female  the  sac  bears  the 
same  relation  to  the  round  ligament  as  to  the  cord  in  the  male  and  is  very 
closely  attached  to  it. 

There  are  some  conditions  in  which  the  hernial  sac  may  be  incomplete,  such 
as  sliding  hernia  of  the  sigmoid,  cecum  and  occasionalh-'  of  the  bladder.  In 
such  cases  the  anterior  portion  of  the  sac  is  formed  of  peritoneum  and  the 
posterior  portion  is  continuous  with  the  wall  of  the  sigmoid,  cecum  or  bladder, 
whichever  one  may  be  involved.  Clinically  it  is  important  to  bear  this  con- 
dition in  mind,  in  order  not  to  injure  the  intestinal  wall  on  attempting  to 
open  the  hernial  sac. 

It  is  clear  that  a  sliding  hernia  can  occur  only  in  case  of  an  intestine 
which  is  not  completely  surrounded  with  peritoneum.  Were  the  peritoneum 
constantly  normal  in  its  arrangement,  sliding  hernia  of  the  ascending  and 
descending  colon  into  the  inguinal  or  femoral  canals  only  would  be  possible, 
but  this  is  not  the  case,  because  the  cecum  and  the  sigmoid  are  not  always 
completely  surrounded  with  peritoneum.  Whenever  the  sac  cannot  be  readily 
isolated,  the  possibility  of  the  presence  of  this  condition  must  consequently 
be  constantly  borne  in  mind  to  prevent  injury  to  the  intestine. 

In  these  cases  as  much  as  is  present  of  the  sac  should  be  preserved  in  order 
that  the  peritoneal  defect  may  be  corrected  in  the  intestine  before  the  latter  is 
replaced  in  the  peritoneal  cavity,  so  that  there  will  in  the  future  be  a  fairly 
good  mesentery. 

The  remaining  steps  af  the  operation  differ  in  no  way  from  those  usually 
taken  in  the  closure  of  a  hernial  opening  after  the  sac  has  been  ligated  and 
removed. 

In  direct  inguinal  hernia  in  the  male  the  hernia  descends  below  the  epi- 
gastric vessels  and  out  through  the  external  ring.  It  pushes  the  cord  directly 
in  front  of  it,  or  to  one  side,  but  does  not  bear  such  a  definite  and  intimate 
relation  to  the  cord  as  is  found  in  oblique  inguinal  hernia.  The  sac  is  not  so 
liable  to  descend  into  the  scrotum  as  in  oblique  inguinal  hernia,  but  is  more 
likely  to  take  an  outward  direction. 

The  size  and  shape  of  the  sac  in  inguinal  hernias  vary  greatly.  In  scrotal 
hernia  the  sac  is  most  often  pear-shaped. 

It  is  not  uncommon  to  find  a  constriction  at  about  the  center,  forming  an 
hour-glass  shaped  sac.  The  sac  is  also  frequently  sacculated,  and  occasionally 
to  such  an  extent  that  a  complete  double  sac  is  formed. 

Varied  contents  of  the  sac.  The  contents  of  the  hernial  sac  also  varies 
greatly.  Nearly  every  organ  in  the  abdominal  cavity  has  been  found  to  form 
a  part  or  the  whole  of  the  contents  of  the  sac.  The  most  frequent  contents  are 
the  omentum  and  small  intestine,  then  some  portion  of  the  large  intestine, 
and  next  the  bladder.  In  femoral  hernia  the  intestine  rarely  forms  any  por- 
tion of  the  contents  except  in  cases  of  strangulation.    Various  portions  of  the 


332  GENERAL  SURGERY  OF  THE  ABDOMEN 

small  intestine  may  be  caught  in  the  hernial  sac,  but  the  portion  most  fre- 
quently involved  is  a  loop  a  short  distance  above  the  ileo-cecal  valve,  which  has 
a  longer  mesentery  than  the  other  portions  of  the  small  intestine. 

The  edge  of  the  bladder  is  quite  frequently  found  in  the  sac  in  inguinal 
hernias  and  occasionally  a  diverticulum  or  pouch  of  the  bladder  forms  a 
considerable  part  of  the  sac  and  also  of  its  contents.  This  is  most  frequent 
in  patients  who  are  rather  obese  and  in  whom  there  is  a  diffuse  bulging  over 
the  inguinal  canal,  instead  of  having  a  pear-shaped  sac  descending  into  the 
scrotum. 

The  appendix  has  been  found  many  times  in  the  sac  of  inguinal  hernia, 
and  R.  E.  Webster  has  reported  a  case  of  strangulated  left  inguinal  hernia  in 
which  a  Meckel's  diverticulum  constituted  the  contents  of  the  sac. 

The  ovary  and  tube  together,  or  the  ovary  and  tube  separate,  have  fre- 
quently been  found  both  in  femoral  and  inguinal  hernias,  and  a  hernial  sac 
containing  the  uterus  has  been  reported  a  few  times. 

Etiology  of  hernia.  Oblique  inguinal,  umbilical  and  femoral  hernia  occur 
at  points  which  are  naturally  weak  because  of  the  normal  opening  through 
the  abdominal  wall  during  fetal  life.  In  many  cases  of  oblique  inguinal,  and  in 
some  of  the  umbilical  variety,  these  openings  have  never  been  closed,  so  that 
the  hernia  is  in  consequence  congenital. 

The  theory  that  oblique  inguinal  hernia  is  primarily  always  due  to  an 
incomplete  closure  of  the  processus  vaginalis  testis  is  being  accepted  by  many 
surgeons.  This  is  due  largely  to  the  teachings  of  Mr.  Hamilton  Russell,  of  Mel- 
bourne, concerning  the  "saccular"  theory  for  the  etiology  of  hernia.  In 
accepting  this  theory,  it  does  not  mean  that  every  individual  with  an  incom- 
pletely obliterated  process  must  develop  a  hernia,  but  the  occurrence  depends 
secondarily  upon  the  various  conditions  usually  enumerated  as  the  exciting 
and  predisposing  causes  of  hernia. 

Frequently  the  tissues  around  the  hernial  opening  are  much  weaker  than 
normal,  so  that  they  will  give  way  much  more  easily.  This  is  true  especially 
in  patients  who  have  one  or  both  parents  with  a  similar  defect.  (More  than 
one-third  of  all  patients  suffering  from  hernia  give  a  history  of  hereditary 
tendenc}^  in  this  direction.) 

The  fact  that  the  spermatic  cord  passes  through  the  inguinal  canal  makes 
this  form  of  hernia  most  frequent.  A  long  omentum  with  its  ability  to  become 
insinuated  in  any  opening,  however  small  it  may  be,  is  a  common  predisposing 
cause  in  the  formation  of  hernia.    The  same  is  true  of  a  long  mesentery. 

The  presence  of  a  great  quantity  of  fat  in  the  abdominal  wall  markedly 
weakens  this  structure,  first,  from  the  fact  that  lobes  of  fat  will  invade  the 
natural  openings  and  separate  the  connective  tissue  and  muscular  layers  whose 
function  it  is  to  prevent  the  formation  of  hernia ;  secondly,  because  with  the 
accumulation  of  great  quantities  of  fat  in  the  connective  tissue  spaces  of  the 
abdominal  wall  the  muscles  themselves  become  softened  on  account  of  a  cer- 
tain amount  of  fatty  degeneration  which  takes  place  in  these  tissues.  More- 
over, at  the  same  time  there  is  always  a  corresponding  increase  in  the  amount 
of  fat  Avithin  the  abdominal  cavity,  which  not  only  favors  the  formation  of 
hernia  because  of  its  weight,  but  also  because  it  increases  the  intra-abdominal 
pressure. 

Exciting  causes.  The  chief  exciting  cause  is  increased  or  abnormal  intra- 
abdominal pressure.  This  may  be  very  violent  and  of  only  short  duration,  as 
in  lifting  heavy  weights,  falling  a  great  distance  or  with  very  great  force, 
violent  coughing  or  sneezing,  etc.  In  such  cases  the  tissues  are  virtually  torn, 
making  an  opening  through  which  the  hernial  contents  protrude.  Again,  the 
abnormal  intra-abdominal  pressure  may  be  less  violent  and  more  continuous, 
as  where  there  is  a  long-continued  cough,  chronic  constipation,  or  an  obstruc- 
tion of  the  urethra   on  account  of  phimosis,  stricture,   enlargement  of  the 


GENERAL  SURGERY  OF  THE  ABDOMEN  333 

prostate  gland  or  stone  in  the  bladder.  Tlie  same  is  true  of  gaseous  distension 
of  the  stomach  and  intestines  due  to  digestive  disturbances.  Adhesions  fol- 
lowing peritonitis  due  to  appendicitis,  or  infection  through  the  Fallopian  tubes, 
is  likely  to  have  the  same  effect.  In  short,  anything  which  may  cause  abnormal 
intra-abdominal  pressure,  either  acute  or  chronic,  is  likely  to  bring  about  the 
formation  of  a  hernia,  especially  if  there  is  a  predisposition  thereto. 

General  treatment.  In  many  of  these  cases  a  properly-fitting  truss  will 
secure  for  the  patient  a  relative  degree  of  comfort  and  safety,  but  necessitates 
the  wearing  of  an  apparatus  which  is  at  best  unpleasant  and,  in  summer  espe- 
cially, annoying,  uncomfortable,  fatiguing  and  sometimes  painful.  Aside  from 
this  the  patient  is  constantly  exposed  to  the  risk  of  having  strangulation,  which 
is,  under  all  circumstances,  very  dangerous,  and  quite  a  considerable  propor- 
tion of  all  persons  suffering  from  hernia  lose  their  lives  sooner  or  later  as  a 
result  of  this  sequel.  Many  persons  suffering  from  hernia  find  it  difficult  to 
compete  with  others  of  their  rank  and  qualifications  because  of  this  handicap, 

Pre-operative  management.  In  a  general  way  the  preparatory  treatment 
is  the  same  for  these  patients  as  for  those  about  to  undergo  any  other  serious 
operation,  with  the  addition,  it  may  be,  of  certain  steps  which  are  intended  to 
eliminate  as  much  as  possible  some  of  the  predisposing  causes. 

It  is  well,  for  instance,  to  place  patients  who  have  a  great  accumulation 
of  fat  in  the  abdominal  wall  upon  a  systematic  course  of  treatment  for  the 
reduction  of  this  fat,  if  possible,  before  operation  is  done.  "We  have  usually 
employed  the  following  diet  with  excellent  results,  the  patient  losing  from 
three  to  ten  pounds  per  week;  the  general  appearance  and  strength  improving 
constantly  during  this  treatment.  Many  have  lost  a  total  of  from  thirty  to 
sixty  poiuids  in  weight,  and  in  a  few  very  obese  patients  the  loss'  has  even 
exceeded  one  hundred  pounds. 

The  diet  may  be  varied  to  suit  the  individual  case. 

DIET  LIST     . 

Breakfast. — 

Tea — 4%  oz. — A  very  small  cup. 

Milk — 2/3  oz. — One  and  a  half  tablespoonsful. 

Sugar — 75  grs. — A  small  lump. 

Bread — 375  grs.^A  very  small  slice. 
Dinner. — 

Sour  wine — 3  1/3  oz. — ^A  wineglassful. 

One  egg,  or  lean  meat — 10  oz. 

Lettuce  with  vinegar — 1  2/3  oz. 

A'egetables — 1  2/3  oz. 

Bread — 375  grs. 
Supper. — 

AVine — 1/2  pint. 

"Water — 1/2  pint. 

Quarter  small  chicken,  or  8  oz.  lean  meat. 

One  egg. 

Bread — 375  grs. 
In  order  to  make   the  plan  clear  to  the  housekeeper  who   supplies  the 
meals  we  give  each  patient  the  following  pointed  directions : 

DIET 

Kindly  follow^  this  list  carefully.  There  will  be  three  breakfasts,  three 
luncheons  and  three  suppers  any  one  of  which  you  may  choose,  but  you  must 
never  eat  more  than  is  contained  in  any  one  of  these  meals.    In  place  of  any 


334  GENERAL  SURGERY  OF  THE  ABDOMEN 

one  of  these  meals  at  any  time  you  may  substitute  one  pint  of  buttermilk 
if  you  like. 
Breakfast. — 

No.  1.  One  soft-boiled  egg,  one  small  piece  of  toast. 
No.  2.  Half  a  pound  of  lean  steak,  one  baked  apple. 
No.  3.  Half  a  pint  of  hot  milk  and  one  small  piece  of  bread. 
Luncheon. — 

No.  1.  Half  a  pint  of  soup  and  one  small  piece  of  bread. 
No.  2.  Half  a  pound  of  fresh  fish,  broiled,  one  dish  of  lettuce  with  pep- 
per, salt  and  lemon-juice. 
No.  3.  One  pint  of  buttermilk  and  one  small  piece  of  bread. 
Supper. — 

No.  1.  Half  a  pound  of  beef,  one  dish  of  spinach,  or  one  dish  of  tur- 
nips, or  one  dish  of  boiled  onions. 
No.  2.  Half  a  pound  of  lean  mutton,  one  dish  of  cabbage,  or  one  dish 

of  cauliflower,  or  of  squash. 
No.  3.  Half  a  breast  of  chicken,  one  dish  of  lettuce  with  pepper,  salt 
and  lemon-juice,  or  fruits  cooked  without  sugar,  or  one  dish 
of  cooked  vegetables,  or  one  glass  of  fruitjuice. 
You  should  drink  nothing  at  all  during  your  meals,  nor  for  one  hour  be- 
fore or  after  eating.     No  water,  tea,  coffee  or  fluids  of  any  kind.     Between 
meals  you  may  drink  water,  either  hot  or  cold,  flavored  with  lemon  or  orange 
juice.    Take  absolutely  nothing  containing  alcohol. 

Take  breathing  exercises  regularly  morning  and  evening.  Take  a  walk 
out  of  doors  every  day.  Increase  the  length  of  your  walk  gradually,  and  also 
the  speed. 

These  meals  may  be  changed  about  to  suit  the  inclination  of  the  patient. 
It  is  quite  as  well  to  take  the  food  prescribed  for  lunch  at  breakfast  time, 
and  vice  versa.  Men  who  are  in  business  frequently  find  the  breakfast  in- 
sufficient, and  the  bread  may  then  be  omitted  and  eight  to  twelve  ounces 
of  lean  steak  substituted. 

Drink  nothing  during  the  meal,  nor  for  an  hour  before  or  after,  except 
as  given  in  the  above  list.  When  thirsty  during  the  day  drink  a  little  sour 
wine  or  sour  lemonade. 

Aside  from  this  the  patient  is  advised  to  walk  systematically,  beginning 
with  that  which  is  perfectly  comfortable  on  the  first  day  and  increasing  it 
one-fourth  mile  daily  until  the  distance  reaches  from  six  to  twelve  miles. 
At  first  the  habitual  speed  of  walking  should  be  practised,  but  this  should 
be  increased  until  the  patient  covers  the  entire  distance  at  a  maximum  speed 
for  his  strength.  During  this  walk  he  should  breathe  very  deeply  through 
the  nose,  the  lips  remaining  closed. 

Other  hygienic  measures  like  hot-baths  followed  by  cold  shower,  massage 
and  various  gymnastic  exercises  may  be  added  to  this  plan. 

All  this  will  not  only  reduce  the  amount  of  fat  in  the  abdominal  wall, 
but  also  to  a  great  extent  in  the  omentum  and  mesentery  and  underneath 
the  peritoneum,  thus  reducing  the  intra-abdominal  pressure  to  a  marked  de- 
gree, and  at  the  same  time  increasing  the  firmness  of  all  the  tissues  in  the 
vicinity  of  the  hernia. 

If  there  is  an  abnormal  amount  of  intra-abdominal  pressure  due  to  gaseous 
distension  of  the  abdomen  caused  by  indigestion  this  should  be  corrected. 
The  same  is  true  of  constipation,  or  obstruction  to  the  passage  of  urine,  or 
a  chronic  bronchitis.  In  short,  so  far  as  possible,  it  is  wise  to  eliminate  the 
predisposing  causes  of  hernia  before  the  operation  for  radical  cure  is  under- 
taken. 

The  same  rules  should  be  borne  in  mind  in  the  after-treatment.     Provi- 


GENERAL  SURGERY  OF  THE  ABDOMEN 


335 


sion  should  be  made  against  the  recurrence  of  these  predisposing  causes  after 
the  patient  has  once  heen  relieved  of  his  hernia  by  an  operation. 

INGUINAL  HERNIA 

Typical  case.  Our  patient  is  thirty-eight  years  of  age  and  a  farm-laborer  by  occupation. 
One  sister  died  at  eighteen  and  one  brother  at  twenty  years  of  age.  His  mother  suffered 
from  a  rupture.  Patient  had  whooping  cough  in  childhood  and  typhoid  fever  at  eighteen; 
was  weakly  and  ill  most  of  the  time  until  the  age  of  twenty.  He  had  pneumonia  at  the 
age  of  thirty-three.  At  the  age  of  thirty  patient  felt  some  pain  in  both  inguinal  regions, 
after  climbing  a  tall  tree.  One  week  later  he  jumped  suddenly  out  of  bed,  when  he  experienced 
a  pain  in  the  left  inguinal  region.  At  this  time  he  noticed  a  small  bulging  over  the  left 
inguinal  canal.     He  wore  a  truss  for  three  years,  when  he  was  apparently  cured.     At  this 


■9\ 


'-'."f. '  ■ 


Typical  Bilateral  Indirect  Oblique 
Inguinal  Hernia. 


Indirect   Oblique   Inguinal   Hernia 

Descending  into  the   Scrotal   Sac. 

Treatment — Herniotomy. 


time  he  suffered  from  pneumonia,  coughed  a  great  deal,  and  when  he  had  recovered  from 
this  sickness  found  that  the  hernia  had  returned.  He  again  wore  a  truss,  which  retained 
the  hernia,  but  the  hernial  opening  showed  no  further  tendency  toward  closing. 

Three  weeks  ago,  after  patient  had  been  working  hard  in  the  field,  he  noticed  a  slight 
bulging  on  the  right  side,  which  has  increased  constantly  until  it  has  now  attained  the  size 
of  a  hen's  egg.  Neither  hernia  has  caused  pain.  There  has  been  no  tendency  towards 
strangulation.  When  the  patient  is  in  a  recumbent  position  the  hernise  always  reduce  sponta- 
neously. 

The  patient  is  fairly  well  nourished.  Lungs,  heart,  kidneys  and  abdominal  organs  are 
normal;  the  tongue  is  slightly  coated;   appetite  good;  bowels  regular. 

The  abdomen  is  normal  except  for  a  marked  weakening  over  both  internal  abdominal 
rings,  causing  a  bulging  the  size  of  a  hen's  egg  over  each  inguinal  canal  when  the  patient 
is  in  the  erect  position,  and  this  is  still  further  exaggerated  upon  coughing.  The  enlargement 
is  a  little  more  marked  upon  the  right  side.  Patient  complains  of  a  feeling  of  weakness  at 
this  point  in  the  abdominal  wall  and  he  is  compelled  to  support  it  with  his  hand  when  he 
attempts  to  lift  any  weight.  The  right  inguinal  canal  easily  admits  the  tips  of  two  fingers; 
the  left  the  tip  of  one  finger  only. 

The  contents  of  the  canal  can  be  easily  reduced  into  the  abdominal  cavity  by  means  of 


336 


GENERAL  SURGERY  OF  THE  ABDOMEN 


a  slight  amount  of  pressure,  and  upon  taking  the  recumbent  position  the  bulging  disappears 
at  once. 

All  of  the  conditions  are  so  clear  that  there  can  be  no  difficulty  in  making  a  diagnosis 
of  uncomplicated  double  inguinal  hernia. 

Differential  diagnosis.  It  is  almost  impossible  to  make  a  wrong  diagnosis 
in  simple  cases  of  reducible  inguinal  hernia,  but  it  is  quite  different  if  some 
complication   exists.     The  most   common   of  these   consist   of  adhesions.     If 


Bassini  's  Operation  for  Inguinal  Hernia  with  Imbrication  of  Structures  as  Advised  by 

Dr.  E.  Wyllys  Andrews. 


some  of  the  hernial  contents,  such  as  the  omentum  or  intestine,  are  adherent 
to  the  hernical  sac,  or  if  the  hernia  is  complicated  by  an  acute  inflammatory 
condition,  it  may  be  mistaken  for  an  inflammation  of  the  inguinal  lymphatic 
glands. 

The  latter  condition  is,  however,  usually  preceded  by  an  infection  of  the 
urethra  or  the  prepuce,  or  of  some  portion  of  the  lower  extremity  such  as 
may  come  from  an  infected  corn  or  from  some  slight  abrasion  of  the  skin. 


GENERAL  SURGERY  OF  THE  ABDOMEN  337 

If  the  hernia  has  extended  down  into  the  strotum  it  may  be  difficult  to 
differentiate  it  from  hematocele  or  a  hydrocele,  although  one  can  usually 
see  rays  of  light  shining  through  the  latter  by  placing  a  small  tube  against 
the  scrotum  and  holding  a  light  on  the  opposite  side.  Moreover,  by  grasp- 
ing the  tissues  opposite  the  external  abdominal  ring  between  the  finger  and 
thumb  one  can  always  feel  the  tissues  of  the  cord  above  a  hydrocele,  but  not 
above  a  hernia,  except  in  children  suffering  from  an  irreducible  hydrocele 
of  the  cord,  to  be  considered  later.  On  the  left  side  a  large  varicocele  is 
sometimes  mistaken  for  hernia  and  vice  versa.  This,  however,  should  not 
occur,  because  the  enlarged  veins  have  a  peculiar,  ivormlike  feeling  in  vari- 
cocele, which  may  be  easily  recognized. 

Occasionally  an  inguinal  hernia  and  a  femoral  hernia  occur  in  the  same 
patient,  and  in  a  few  cases,  instead  of  extending  in  the  direction  of  the 
inguinal  canal  into  the  scrotum  an  inguinal  hernia  will  descend  to  the  upper 
portion  of  the  scrotum  and  then  be  deflected  outward  to  a  point  opposite 
the  femoral  ring,  and  thus  have  the  appearance  of  a  femoral  hernia. 

In  a  similar  manner  a  femoral  hernia,  instead  of  descending  after  protrud- 
ing through  the  femoral  opening,  may  extend  upward  and  form  a  swelling 
in  the  region  of  the  inguinal  canal  and  thus  have  the  appearance  of  an 
inguinal  hernia.  So  long  as  the  hernia  is  reducible  in  either  case  the  diagno- 
sis can  readily  be  made,  because  the  opening  through  which  the  hernia  has 
protruded  can  be  demonstrated  by  digtal  examination;  if  this  is  above 
Poupart's  ligament  it  is  an  inguinal,  if  below,  a  femoral  hernia. 

Tumors  are  very  rare  in  the  region  of  the  inguinal  canal,  but  we  have  seen 
a  lipoma  and  several  sarcomata  which  had  been  diagnosed  as  inguinal  hernia. 

Etiology.  There  can  be  no  doubt  but  that  there  is  an  hereditary  tendency 
in  many  families  to  the  formation  of  hernia.  If  both  parents  in  a  family 
suffer  from  this  defect  some  of  the  children  are  almost  certain  to  be  afflicted 
in  the  same  manner.  The  well-known  fact  that  special  defects  in  families  are 
likely  to  be  inherited  is  shown  in  this  disease.  There  is  a  much  larger  pro- 
portion of  hernige  in  nationalities  in  which  intermarriage  between  first  cousins 
is  freely  practised  than  in  others  in  which  this  is  forbidden. 

The  natural  opening  in  the  inguinal  canal  in  the  male,  due  to  the  descent 
of  the  testicle,  makes  the  occurrence  of  inguinal  hernia  much  more  common 
than  in  the  female. 

Long-continued,  exhausting  diseases  cause  a  relaxation  of  the  tissues  of  the 
abdominal  wall,  which  predisposes  to  the  formation  of  hernia. 

In  a  considerable  proportion  of  cases  the  inguinal  canal  had  never  been 
completely  closed  after  the  descent  of  the  testicle,  and  it  required  only  a  slight 
dilatation  of  the  internal  abdominal  ring,  followed  by  a  sudden  increase 
of  pressure,  to  force  down  some  of  the  intra-abdominal  contents,  and  the 
hernia  is  thus  established.    A  long,  thin  omentum  greatly  favors  this  last  step. 

Indications  for  operation.  In  our  typical  patient  the  hernia  can  be  readily 
reduced  and  retained  by  means  of  a  truss,  hence  the  conditions  are  very  simi- 
lar to  those  discussed  in  connection  with  femoral  hernia.  We  can  undoubtedly 
relieve  this  patient  of  the  discomforts  of  wearing  a  truss,  and  the  dangers  of  a 
possible  strangulation,  by  a  safe  operation,  which  will  disable  him  for  work 
not  longer  than  one  month.  There  can  consequently  be  little  doubt  concern- 
ing the  wisdom  of  his  choice  of  treatment. 

Preparation  for  operation.  The  intestinal  canal  should  be  thoroughly 
emptied  by  the  administration  of  two  ounces  of  castor  oil  the  day  before  opera- 
tion, followed  by  a  large  soap  and  water  enema  that  evening  and  another 
early  the  morning  of  operation.  The  field  of  operation  should  be  shaved  the 
evening  before  and  the  following  morning  the  patient  should  take  a  hot  soap 
and  water  tub  bath.    As  soon  as  the  patient  is  anesthetized  the  skin  area  is 


338 


GENERAL  SURGERY  OF  THE  ABDOMEN 


washed  thoroughly  with  soap  and  water  (bemg  careful  not  to  cause  irritation), 
then  it  is  washed  Avith  1  to  2,000  bichloride  solution,  then  with  alcohol.  The 
surface  is  dried  and  painted  with  full-strength,  compound  tincture  of  iodine. 
Operative  technique.  An  incision  ten  to  fifteen  centimeters  in  length  is 
made  in  the  direction,  and  over  the  center,  of  the  inguinal  canal,  beginning  at 


Ferguson  's  Operation  for  Inguinal  Hernia. 

T.  F.,  transversalis  fascia;  I.  R.,  internal  ring;  P.  L.,  Poupart's  ligament;  I.  O.,  internal 
oblique  muscle;  A,  aponeurosis  of  the  external  oblique  muscle;  C,  cremaster  muscle;  C.  T., 
conjoined  tendon. 

a  point  two  centimeters  above  the  scrotum.  This  is  carried  through  the  skin 
superficial  fascia  and  fat,  exposing  the  fascia  of  the  external  oblique  abdominal 
muscle  with  the  hernial  sac  protruding  at  the  lower  end  of  the  inguinal  canal. 
The  fascia  of  the  external  oblique  is  now  slit  up  in  the  direction  of  the 
inguinal  canal  to  a  point  five  centimeters  above  the  internal  abdominal  ring. 
The  edges  of  this  are  now  carefully  retracted,  and  the  soft  tissues,  consisting 
of  fat,  portions  of  the  cremaster  muscle  and  connective  tissue,  are  carefully 


GENEEAL  SUEGERY  OF  THE  ABDOMEN 


339 


dissected  away,  leaving  the  anatomical  structures  plainly  exposed.  The  fat 
can  be  removed  most  perfectly  and  rapidly  by  stripping  bet\Yeen  the  layers 
of  a  piece  of  moist  gauze  held  between  the  fingers  and  thumb.  This  exposes 
the  ledge  of  Poupart's  ligament  and  the  fascia  of  the  external  oblique  below, 
the  internal  oblique  and  transversalis  fascia  and  the  fascia  of  the  external 


Ferguson's  Operation  for  Inguxnal  Hernia. 

A,  aponeurosis  of  the  external  oblique  muscle;  P.  L.,  Poupart's  ligament;   I.  0.,  internal 
oblique  muscle;   T.  F.,  transversalis  fascia;   C,  cremaster  muscle. 


oblique  above,  and  between  these  the  hernial  sac  and  the  spermatic  cord ;  and 
to  the  outer  side,  the  fibers  of  the  internal  oblique. 

The  hernial  sac  is  now  carefully  dissected  out,  caution  being  taken  not 
to  injure  the  tissues  of  the  spermatic  cord,  which  in  this  case  we  find  con- 
tinuous with  the  upper  portion  of  the  sac,  showing  that  we  have  to  deal  with 
a  congenital  hernia,  the  tunica  vaginalis  having  remained  open  since  birth, 
the  internal  ring,  however,  being  so  nearly  closed  that  there  was  no  protrusion 
of  omentum  until  many  years  later. 


340 


GENERAL  SURGERY  OF  THE  ABDOMEN 


In  order  to  facilitate  the  separation  of  the  upper  portion  of  the  sac  we 
will  open  the  latter.  It  contains  a  long,  thin  portion  of  omentum.  This  is 
drawn  down  gently  as  far  as  it  will  come  witliout  using  any  force.    It  is  spread 


Ferguson  's  Operation  for  Inguinal  Hernia. 

out  and  the  vessels  are  ligated  by  passing  around  them  catgut  ligatures  at 
each  point  at  which  they  can  be  seen  by  holding  up  the  spread  omentum  to  the 
light.     Then  the  omentum  is  cut  away  beyond  these  ligatures,  preserving 


.  GENERAL  SURGERY  OF  THE  ABDOMEN 


341 


enougli  tissue  to  prevent  slipping.  The  sac  is  now  dissected  up  to  a  point 
quite  within  the  abdominal  cavity ;  it  is  then  transfixed  with  a  needle  carrying 
a  double  catgut  ligature  and  tied  so  as  to  prevent  slipping.  The  sac  is  cut 
away,  care  being  taken  to  leave  enoiiy]!  ti-<iii'  to  prevent  the  slipping  of  the 


Ferguson  's  Operation  for  Inguinal  Hernia. 

With  deep  sutures  tied  uniting  internal  oblique  abdominal  and  transversalis  muscles 
and  conjoined  tendon  to  Poupart's  ligament.  Showing  the  fascia  of  external  oblique  abdominal 
muscle;  conjoined  tendon;  internal  oblique  abdominal  muscle.  The  untied  sutures  show  the 
method  of  overlapping, — Andrews'  imbrication  principle  as  applied  to  Ferguson's  operation. 

ligature.  The  stump  is  now  retracted  within  the  abdominal  cavity  by  the 
elasticity  of  the  peritoneum. 

The  steps  which  have  just  been  described  are  exceedingly  important,  espe- 
cially the  careful  removal  of  the  soft  tissues,  the  hernial  sac  and  the  omentum, 
because  neglect  of  any  one  of  these  points  would  tend  to  cause  a  recurrence. 

The  internal  oblique  muscle  and  transversalis  fascia  are  now  carefully 
united  with  interrupted  sutures  of  chromicized  catgut  to  the  ledge  upon  the 


342  GENERAL  SURGERY  OF  THE  ABDOMEN 

under  surface  of  Poupart's  ligament,  the  edge  of  the  fascia  of  the  external 
oblique  being  carefully  retracted. 

In  applying  these  sutures,  it  is  well  to  bear  in  mind  the  possibility  of 
injuring  the  deep  epigastric  vessels  by  carelessly  grasping  the  tissues  above 
with  the  stitch,  or  the  iliac  vessels  below  in  the  same  manner.  The  simplest 
way  to  avoid  injuring  the  latter  is  to  insert  the  needle  through  Poupart's 
ligament  from  within  outward. 

The  fascia  of  the  external  oblique  muscle  is  then  sutured.  The  skin  is  then 
sutured  over  all. 

This  method,  known  as  Ferguson's  operation,  has  the  advantage  of  closing 
the  inguinal  canal  perfectly,  firmlj^  and  permanently,  and  at  the  same  time 
leaving  the  tissues  of  the  spermatic  cord  undisturbed. 

Since  the  publication  of  this  method  by  Ferguson  we  have  used  it  because 
it  combined  all  of  the  good  qualities  of  Bassini's  operation,  which  we  had 
practised  with  most  excellent  results  for  a  number  of  years  previously,  and 
has  the  advantage  of  being  simpler  in  that  it  does  not  disturb  the  tissues  of  the 
spermatic  cord. 

In  order  to  illustrate  the  latter  method,  however,  especially  as  it  is  the  one 
still  in  use  by  most  of  the  best  surgeons,  we  will  perform  Bassini's  operation 
upon  the  other  side.  For  the  sake  of  simplicity,  we  can  make  use  of  the  illus- 
trations just  shown  of  a  herniotomy  upon  the  left  side,  because  all  the  steps, 
with  one  exception,  are  identical. 

The  incision,  the  exposure  of  the  anatomical  layers,  the  removal  of  the 
soft  tissues  and  the  hernial  sac  are  the  same.  In  the  last  step,  however,  we 
find  this  difference :  The  sac  is  not  continuous  with  the  tissues  of  the  sper- 
matic cord,  but  is  simply  adherent  by  means  of  delicate  fibers  of  connective 
tissue,  showing  that  on  this  side  we  have  an  acquired  and  not  a  congenital 
hernia. 

We  also  find  that  the  sac  contains  no  omentum.  It  is  likely  that  this 
descended  into  one  side  occasionally  and  then  into  the  other,  or  the  other 
side  may  have  contained  omentum  and  this  side  intestines  regularly.  Hav- 
ing disposed  of  the  hernial  sac  as  before,  we  make  the  step  in  the  operation 
in  which  the  two  methods  named  differ.  The  tissues  of  the  spermatic  cord 
are  carefully  loosened  from  all  of  the  surrounding  tissues.  Then  we  elevate 
it  from  the  floor  of  the  inguinal  canal  by  means  of  a  blunt  hook  and  insert 
the  stitches  of  chromicized  catgut.  These  stitches  are  applied  precisely  as 
before,  grasping  the  same  tissues,  two  of  them  being  applied  above  the  cord 
and  the  others  underneath  the  elevated  cord,  so  that  the  latter  passes  out 
between  the  second  and  third  stitch,  counting  from  the  outer  side.  Six  stitches 
will  usually  suffice.  They  may  be  applied  with  greater  regularity  if  they  are 
not  tied  until  all  are  in  place.  The  same  care  must  be  taken  to  prevent  the 
injury  of  the  deep  epigastric  and  iliac  vessels  as  before. 

The  two  stitches  above  the  cord  are  of  the  greatest  importance,  because 
it  is  at  this  point  that  recurrence  is  likely  to  take  place.  After  these  stitches 
have  been  tied  the  fascia  of  the  external  oblique  muscle  and  the  skin  are 
sutured  as  before. 

Variations  in  technique.  Occasionally  the  tissues  to  the  inner  side  of  the 
inguinal  canal  are  so  attenuated  that  it  seems  difficult  to  secure  a  permanent 
closure  of  the  hernial  opening.  In  this  event  it  may  become  necessary  to 
utilize  the  rectus  abdominis  muscle- — Bloodgood's  method.  The  fascia  cover- 
ing the  outer  edge  of  the  rectus  abdominis  muscle  is  split  longitudinally  and 
the  muscle  is  then  sutured  to  Poupart's  ligament,  together  with  the  conjoined 
tendon  of  the  internal  oblique  and  transversalis. 

Prognosis.  Both  of  these  operations,  if  performed  with  great  care,  will 
result  in  a  permanent  cure  of  inguinal  hernia  in  almost  every  case,  provided 


GENERAL  SURGERY  OF  THE  ABDOMEN  343 

that  the  patient  prevents  for  the  future  the  recurrence  of  abnormal  intra-ab- 
dominal pressure. 

In  the  female  patient  the  operation  is  done  precisely  in  the  same  man- 
ner, with  the  exception  that  the  round  ligament,  which  corresponds  to  the 
tissues  of  the  spermatic  cord,  is  practically  disregarded. 

FEMORAL  HERNIA 

Clinical  case.  An  unmarried  ■woman,  twenty-eight  years  of  age,  a  servant  by  occupation, 
gives  the  following  history: 

Her  parents,  brothers  and  sisters  are  well.  She  was  well  and  strong  as  a  child;  menstrua- 
tion since  the  age  of  sixteen,  regular  and  normal.  She  has  worked  hard  as  a  servant  since 
the  age  of  twenty.  At  twenty-two  she  first  noticed  a  slight  protrusion  in  the  region  of  the 
left  femoral  canal.  This  has  increased  gradually.  It  is  now  the  size  of  a  hen 's  egg.  She 
can  reduce  it  readily,  but  suffers  from  a  dragging  pain  when  working  hard;  in  fact,  even 
when  she  is  compelled  to  stand  or  walk  she  is  very  imeomfortable. 

She  is  well  nourished,  the  various  organs  are  normal,  both  as  regards  their  anatomical 
position  and  physiological  functions.  Upon  standing  a  swelling  develops  in  the  left  femoral 
region  to  the  size  of  a  hen's  egg.  The  swelling  disappears  instantly  upon  resuming  the 
recumbent  position,  and  an  opening  that  will  admit  the  tip  of  a  finger  can  be  felt  under 
Poupart's  ligament.     There  is  an  impulse  upon  coughing  or  straining. 

The  history  and  physical  examination  leave  no  doubt  as  to  the  diagnosis.  It  is  an  uncom- 
plicated case  of  femoral  hernia. 

Differential  diagnosis.  If  a  portion  of  the  omentum  becon^es  attached  to 
the  lining  of  the  hernial  sac,  on  account  of  inflammatory  adhesions,  it  may 
occasionally  be  mistaken  for  lymphadenitis  of  the  glands  often  found  in 
this  region. 

Lipoma  has  been  mistaken  for  femoral  hernia ;  the  same  is  true  of  sar- 
coma. All  of  these  conditions  can,  however,  be  eliminated  in  this  case  because 
there  is  a  definite  femoral  canal  when  the  swelling  is  reduced,  and  there  is  a 
distinct  impulse  upon  coughing  or  straining.  Moreover,  the  condition  is  too 
chronic  for  either  sarcoma  or  lymphadenitis. 

The  history  is  interesting  from  one  point  alone,  which  probabh'  explains 
the  origin  of  this  hernia. 

Etiology.  So  long  as  this  patient  remained  at  home  and  simply  performed 
her  share  of  the  duties  in  the  household  of  her  parents,  who  were  working 
people  with  a  small  income,  she  remained  perfectly  well.  She  went  into  service 
as  a  domestic  and  was  compelled  to  labor  beyond  her  strength,  and  conse- 
quently soon  became  relaxed.  When  she  lifted  heavy  wash-boilers,  and  over- 
exerted herself  in  other  "ways,  immediately  the  point  of  weakness  in  her  fe- 
moral region  became  apparent.  The  peritoneal  protrusion  formed  a  hernial 
sac  and  as  the  omentum  or  intestine  was  forced  into  this  sac  the  latter  slowly 
increased,  until  it  acquired  its  present  size. 

Femoral  hernia  is  almost  always  acquired  at  a  time  when  the  patient  is 
exposed  to  an  abnormal  strain,  most  commonly  during  the  child-bearing 
period  or,  as  in  this  case,  during  a  time  of  hard  domestic  service. 

The  treatment  may  be  palliative,  by  means  of  a  truss  which  could  undoubt- 
edly be  adjusted,  or  curative,  by  means  of  an  operation. 

There  are  no  strong  indications  in  this  case.  Her  suffering  is  not  severe, 
she  is  not  disabled  for  work,  nor  is  she  in  great  danger  of  becoming  worse. 
The  only  danger  is  from  strangulation,  and  this  is  not  great,  because  the  open- 
ing through  which  the  hernial  contents  enter  the  sac  seems  to  be  sufficiently 
large  to  permit  an  easy  reduction.  Should  there  develop  a  more  marked  dis- 
proportion between  this  part  and  the  remaining  portion  of  the  sac,  strangula- 
tion would  be  more  likely  to  occur.  "Whatever  is  done  for  this  patient  is  con- 
sequently not  a  matter  of  necessity,  but  one  of  choice. 

Although  a  truss  would  probai3ly  retain  this  hernia,  it  is  not  to  be  chosen 


344  GENERAL  SURGERY  OF  THE  ABDOMEN 

lightly,  for  it  will  be  a  hardship  for  this  patient  to  be  subjected  to  the  discom- 
fort of  wearing  this  very  uncomfortable  instrument  for  the  remainder  of  her 
life.  Moreover,  such  a  course  would  be  connected  with  considerable  expense. 
Trusses  have  to  be  changed  and  repaired  and  are  never  comfortable  to  wear. 

On  the  other  hand,  in  choosing  an  operation  for  this  condition  we  must  be 
reasonably  certain  of  three  things,  viz. :  1.  It  must  be  almost  absolutely  safe. 
(This  patient  is  now  in  good  health  and  is  likely  to  remain  so  for  a  long  time 
if  no  operation  be  performed,  therefore  we  take  a  great  responsibility  in  advis- 
ing an  operation  if  it  is  not  safe.)  2.  The  result  must  be  permanent.  3.  The 
patient  must  not  be  disabled  for  work  for  too  long  a  time. 

It  is  believed  that  all  of  these  conditions  may  obtain  under  right  manage- 
ment. 

The  ordinary  preparations  of  the  patient  in  general  and  of  the  field  of 
operation  are  made. 

Operative  steps.  An  incision  is  made  over  the  most  prominent  portion  of 
the  swelling,  either  parallel  with  the  axis  of  the  body  or  with  Poupart's  liga- 
ment. The  center  of  this  incision  should  be  over  the  middle  of  the  femoral 
canal. 

After  the  skin  and  superficial  fascia  have  been  severed  it  is  best  to  lift  the 
underlying  tissues  by  means  of  two  pairs  of  dissecting  forceps,  in  order  to 
protect  each  successive  layer  of  tissue.  This  will  greatly  facilitate  the  opera- 
tion and  at  the  same  time  increase  the  safety  to  the  patient. 

It  is  usually  not  difficult  to  recognize  the  sac  on  account  of  its  smooth, 
hard  structure,  but  if  the  tissues  have  been  severely  irritated  by  pressure 
from  a  truss  it  then  is  often  more  difficult.  It  can,  however,  always  be 
recognized  after  it  has  been  opened  on  account  of  the  smooth  peritoneal 
lining  and  usually  there  is  an  escape  of  hernial  fluid  as  soon  as  the  sac  is 
incised. 

If  the  sac  is  recognized  before  opening  it  should  be  carefully  separated 
from  the  surrounding  tissues  to  a  point  quite  within  the  femoral  ring.  It 
should  then  be  opened  to  determine  its  contents.  If  it  contains  intestines, 
these  should  be  replaced  into  the  peritoneal  cavity;  if  omentum  which  has 
lost  its  normal  qualities  from  irritation  caused  by  its  confinement  in  the  hernial 
sac,  it  is  well  to  grasp  this  with  forceps  and  draw  it  down  until  a  slight  amount 
of  resistance  indicates  the  fact  that  all  of  that  portion  which  has  occasionally 
descended  in  the  hernial  sac  has  been  drawn  down.  If  the  amount  is  consider- 
able it  should  be  ligated  in  a  sufficient  number  of  portions  to  prevent  its  being 
tied  in  a  mass  large  enough  to  cause  irritation  by  its  presence  in  the  abdominal 
cavity. 

The  ligatures  should  consist  of  catgut  or  fine  silk,  which  should  be  applied 
just  tightly  enough  to  control  the  hemorrhage,  but  not  sufficient  to  crush 
the  tissues.  It  is  well  to  tie  three  times  if  catgut  is  used,  because  the  peritoneal 
fluid  has  a  tendency  to  soften  this  material  and  cause  the  knot  to  loosen.  The 
portion  beyond  the  ligatures  is  cut  away,  care  being  taken  to  leave  enough 
tissue  to  prevent  slipping.  For  the  same  reason  great  care  must  be  used  in 
replacing  the  stump. 

It  is  important  to  dispose  of  the  long,  thin  portions  of  omentum  in  this 
manner,  because  if  left  undisturbed  they  are  likely  to  become  insinuated  in 
any  slight  depression  which  may  be  left  in  the  abdominal  wall  at  the  point  of 
the  operation  and  hence  predispose  to  recurrence. 

The  hernial  sac  is  then  grasped  by  means  of  hemostatic  forceps  and  drawn 
out  of  the  wound  as  far  as  possible  without  tearing  it  loose,  as  shown  in  the 
accompanying  plate.  It  is  then  ligated  as  highly  as  possible  with  catgut  or 
fine  silk.  It  is  best  to  transfix  the  neck  of  the  sac  with  the  ligature  mounted 
upon  a  needle,   and  tie  first  to   one  side   and  then  to  the   other,   so   as  to 


GENERAL  SURGERY  OF  THE  ABDOMEN 


345 


prevent  slipping  of  the  ligature  when  the  pedicle  is  dropped.  A  sufficient 
portion  of  the  sac  should  be  left  outside  of  the  ligature  to  prevent  slipping,  as 
shown  in  the  accompanying  figure. 

AVhen   the   sac  has   been   cut   away   the   stump    will   retract   within   the 
peritoneal  cavity  and  the  ring  be  left  without  a  lining. 


rEMOEAL  Hernia. 

Represents  a  femoral  hernia,  the  entire  sac  having  been  dissected  free  to  a  point  within 
the  femoral  ring,  then  transfixed  and  ligated,  the  sac  being  drawn  out  of  the  wound  with 
forceps,  the  scissors  being  in  position  to  cut  away  the  sac  beyond  the  ligature. 


If  the  cavity  formed  by  the  removal  of  the  sac  contains  masses  of  fat, 
these  should  be  removed.  This  may  be  accomplished  in  a  moment  by  grasp- 
ing these  masses  with  a  piece  of  moist  gauze.  The  fat  seems  to  cling  to  the 
rough  gauze,  while  the  other  structures  slip  through  one's  grasp.  A  perfectly 
clean  dissection  can  be  made  in  this  way  in  a  few  minutes  without  harm  to 
blood-vessels  and  nerves,  which  would  require  a  considerable  time  if  made 
with  dissecting  forceps  and  scalpel. 


346 


GENERAL  SURGERY  OF  THE  ABDOMEN 


This  virtually  completes  the  operation  with  the  exception  of  a  row  of 
superficial  sutures  closing  the  skin. 

If  one  observes  the  anatomical  relations  present,  as  shown  in  the  accom- 
panying diagram,  it  is  plain  that  any  attempt  at  closing  the  femoral  canal 
after  the  hernial  sac  has  been  removed,  must  to  some  extent  favor  the  pro- 
duction of  a  recurrence,  because  this  canal  is  almost  a  perfect  ring  in  most 
cases. 

It  is  a  well-known  fact  that  it  is  practically  impossible  to  keep  any  ring 
in  the  human  body  open  unless  it  is  lined  with  mucous  membrane,  or  includes 
a  serous  membrane  containing  fluid;  consequently  the  most  certain  method 
of  closing  this  ring  consists  in  removing  the  serous  membrane  by  removing 
the  hernial  sac  to  a  point  within  the  abdominal  cavity  and  permitting  the 
ring  to  close  spontaneously.  After  appljnng  this  plan  to  a  large  number  of 
femoral  hernia  we  are  convinced  that  it  is  quite  as  impossible  to  keep  this 
ring  open,  unless  it  is  distorted  by  one  of  the  many  methods  which  have  been 


vi^iw  * 


devised  for  its  closure,  as  it  is  to  keep  any  other  ring  or  canal,  not  lined  with 
serous  or  mucous  membrane,  open.  In  other  words,  all  of  the  methods  which 
have  been  devised  for  closing  this  ring  are  more  or  less  harmful  and  tend 
to  cause  a  certain  number  of  recurrences.  Of  course,  if  the  ring  has  been 
injured  during  the  reduction  of  a  strangulated  hernia,  which  could  not  be 
accomplished  without  cutting  the  ring,  then  this  injury  must  be  repaired  in 
order  to  restore  the  original  favorable  conditions. 

In  case  of  femoral  hernia  due  to  a  severe  traumatism,  especially  a  violent 
blow  upon  this  portion  of  the  body,  Poupart's  ligament  is  occasionally 
separated  for  some  distance  from  its  attachment  and  then  the  femoral  open- 
ing may  not  be  a  perfect  ring,  but  a  broad  gap.  In  such  event  it  is  occa- 
sionally wise  to  freshen  the  edges  of  this  irregular  opening  and  to  construct, 
as  nearly  as  possible,  a  perfect  ring.  There  is,  however,  only  a  very  small 
proportion  of  cases  in  which  this  is  necessary.  Indeed,  it  seems  as  though 
the  tissues  forming  the  femoral  ring  were  increased  in  amount  to  quite  a 
marked  extent  by  the  irritation  due  to  the  presence  of  the  hernia,  and  when 
once  deprived  of  its  serous  lining  by  the  removal  of  the  hernial  sac  this  ring 
contracts  and  closes  with  astonishing  rapidity. 


GENERAL  SURGERY  OF  THE  ABDOMEN  347 

In  most  all  these  patients  it  is  best,  if  possible,  to  institute  systematic 
treatment  for  a  month  or  two  before  performing  the  operation,  with  a  view 
to  reducing  the  obesity. 

After-treatment.  It  is  important  to  prevent  for  a  short  time  the  pro- 
trusion of  the  peritoneum  into  the  femoral  ring  in  order  to  secure  for  this  part 
the  best  possible  conditions  for  contracting  and  closing  permanently.  This 
may  be  favored  in  two  ways ;  first,  by  reducing  the  intra-abdominal  pressure, 
and,  second,  by  keeping  the  contents  of  the  abdominal  cavity  from  approaching 
the  seat  of  the  operation. 

Abnormal  intra-abdominal  pressure  may  be  continuous  as  a  result  of  the 
accumulation  of  gas  in  the  alimentary  canal,  or  as  a  result  of  obesity;  or  it 
may  be  intermittent,  as  in  vomiting  or  coughing,  or  if  the  patient  suffers  from 
constipation  and  has  to  employ  an  abnormal  amount  of  intra-abdominal  pres- 
sure during  the  evacuation  of  the  bowels.  Very  rarely  there  is  a  form  of 
continuous  intra-abdominal  pressure  affecting  hernias  in  case  of  ascites. 

The  intestines  and  the  omentum  may  be  kept  away  from  the  region  of 
operation  by  elevating  the  foot  of  the  bed  six  or  eight  inches  during  the  first 
week  following  the  operation,  at  the  end  of  which  time  the  femoral  ring  will 
have  contracted  sufficiently  to  prevent  any  protrusion.  This  posture,  however, 
is  not  safe  for  patients  who  are  advanced  in  age,  because  in  them  it  is  likely 
to  cause  a  hypostatic  congestion  of  the  lungs,  which  vaay  result  in  pneumonia. 

The  abdominal  pressure  due  to  constipation  can,  of  course,  be  readily 
relieved,  not  only  for  the  time  immediately  following  the  operation,  but  the 
patient  should  understand  the  importance  of  remaining  perfectly  free  from 
this  source  of  trouble.  This  will  also  in  a  great  measure  remove  another 
important  cause  of  abnormal  intra-abdominal  pressure,  that  due  to  gaseous 
distension  of  the  stomach  and  intestines.  This  may  be  overcome  readily  for 
the  time  immediately  following  the  operation  by  having  the  alimentary  canal 
thoroughly  evacuated  on  the  day  before  by  the  free  use  of  a  cathartic,  pref- 
erably by  the  administration  of  two  ounces  of  castor  oil  in  the  foam  of  beer 
or  malt,  the  use  of  enemata  and  the  prohibition  of  any  form  of  food  which 
is  likely  to  produce  gas. 

During  the  first  and  second  days  after  operation  the  patient  is  given  hot 
water  flavored  with  a  little  beef  extract,  if  desired,  then  some  prepared,  pre- 
digested  food  is  given  every  three  hours  for  a  few  days,  then  milk  and  lime 
water,  then  soup,  and  after  ten  days  or  two  weeks  a  light  diet  is  allowed. 

Aside  from  the  immediate  benefit  to  the  patient  there  is  the  further 
advantage  in  this  plan  of  feeding  that  the  digestive  organs  are  given  an 
opportunity  to  rest  and  recuperate  from  the  results  of  their  abuse,  which 
has  usually  been  long-continued  and  vigorous. 

UMBILICAL  HERNIA 

Example.  The  patient  is  forty-nine  years  of  age,  a  house-wife,  whose  history  was  _  of 
no  medical  importance  until  nineteen  years  ago.  At  that  time,  during  an  attack  of  whooping 
cough,  she  noticed  a  slight  bulging  in  the  region  of  the  umbilicus.  Six  months  later  during 
the  birth  of  her  fourth  and  last  child  this  condition  became  considerably  worse.  It  continued 
to  develop  slowly  until  ten  years  ago,  when  it  was  suddenly  increased  on  account  of  a  fall. 
Patient  has  suffered  from  mild  melancholia  for  three  years. 

Patient  is  obese;  pulse  and  temperature,  heart,  lungs  and  kidneys  normal;  bowels  con- 
stipated, tongue  coated.  Abdominal  walls  very  thick.  A  protrusion  is  noticed  at  the  umbilicus, 
the  size  of  a  small  fist,  covered  with  very  thin  skin.  The  mass  cannot  be  reduced  into  the 
peritoneal  cavity  and  is  very  tender  upon  pressure.  There  is  also  tenderness  upon  pressure  in 
the  right  inguinal  region. 

The  condition  present  in  this  patient  can  give  rise  to  but  one  diagnosis — umbilical  hernia. 

Etiology.  This  hernia  was  brought  about  in  the  usual  manner  and  under 
the  usual  conditions.     The  abdominal  wall  had  suff'ered  from  the  effects  of 


348  GENERAL  SURGERY  OF  THE  ABDOMEN 

three  pregnancies ;  it  had  been  weakened  by  an  abnormal  amount  of  fat ;  then 
it  was  taxed  beyond  its  strength  by  the  increased  intra-abdominal  pressure 
caused  by  the  whooping  cough.  To  this  was  added  another  pregnancy  and 
later  a  fall.  Each  of  these  factors  favored  the  further  weakening  of  the 
abdominal  wall  and  the  increase  of  the  hernial  protrusion. 

Influence  of  age.  In  childhood  a  hernia  in  this  position  will  heal  spon- 
taneously in  almost  every  case,  provided  the  increased  intra-abdominal  pres- 
sure is  eliminated,  because  the  opening  is  a  perfect  ring  composed  of  tissue 
which  has  the  tendency  to  contract.  It  is  quite  different  in  patients  over 
thirty  years  of  age.  The  increasing  obesity  primarily  overcomes  the  tendency 
of  the  tissues  forming  the  ring  to  contract ;  moreover,  the  abdomen  broadens, 
while  the  distance  between  the  sternum  and  the  pubis  decreases ;  hence  the 
ring  is  distorted,  which  again  interferes  with  its  closure. 

Still  again,  the  omentum  which  has  been  forced  into  the  hernial  sac  forms 
inflammatory  adhesions  and  this  permanently  prevents  the  closing  of  the  ring. 

Remedial  measures.  Were  the  hernia  reducible  there  might  be  a  choice 
between  palliative  measures  consisting  in  the  fitting  of  a  truss,  and  radical 
measures  consisting  in  an  operation  for  permanent  cure.  We  have  conse- 
quently the  choice  between  giving  this  patient  an  abdominal  bandage  with  a 
pouch-like  arrangement  in  which  to  carry  her  hernia,  and  performing  an 
operation. 

Indications  for  operation.  The  patient  is  virtually  disabled  for  perform- 
ing her  household  duties,  because  there  is  a  constant  dragging  feeling  in  the 
region  of  the  umbilicus  due  to  the  adhesion  of  the  omentum.  For  the  same 
reason  she  is  unable  to  walk,  and  as  a  result  of  this  she  is  compelled  to  lead 
a  sedentary  life,  which  causes  her  obesitj^  to  increase.  There  is  a  kind  of 
vicious  circle  established.  The  increase  in  the  hernia  prevents  her  from 
exercising  sufficiently  to  reduce  her  obesity  and  this  in  turn  favors  the  increase 
in  the  hernia.  Unless  she  is  relieved  of  her  hernia  she  will  become  more  and 
more  helpless. 

Preparatory  treatment.  The  patient  has  come  to  the  city  from  a  distance 
and  is  compelled,  on  account  of  her  financial  circumstances,  to  return  home 
as  soon  as  possible.  It  is  also  impossible  for  her  to  return  home  and  come  to 
the  hospital  later  for  the  operation.  Were  it  not  for  these  circumstances,  it 
would  be  much  better  to  first  place  her  under  treatment  for  the  reduction  of 
her  obesity.  The  same  plan  would  be  followed  which  has  already  been  de- 
scribed in  connection  with  femoral  hernia.  This  being  out  of  question,  we 
have  reduced  the  intra-abdominal  pressure  as  much  as  possible  by  the  use  of 
saline  cathartics,  and  placing  the  patient  upon  a  diet  of  beef -tea  for  a  few 
days,  also  giving  hot  baths  followed  by  cold  showers  and  massage. 

The  Mayo  technique.  Of  all  hernia  this  form  has  been  most  difficult  to 
treat  surgically  and  has  given  a  larger  percentage  of  recurrences  than  any 
other.  This  has,  however,  changed  since  the  introduction  of  Mayo's  operation 
some  twelve  years  ago,  which  has  made  the  results  in  this  form  of  herniotomy 
quite  as  satisfactory  as  in  the  inguinal  variety. 

The  operation  comprises  the  following  steps : 

(1)  Transverse  elliptical  incisions  are  m.ade  surrounding  the  umbilicus 
and  hernia ;  deepened  to  the  base  of  the  hernial  protrusion. 

(2)  The  surfaces  of  the  aponeurotic  structures  are  carefully  cleared  an 
inch  and  a  half  in  all  directions  from  the  neck  of  the  sac. 

(3)  The  fibrous  and  peritoneal  coverings  of  the  hernia  are  divided  in  a 
circular  manner  at  the  neck,  exposing  its  contents.  If  intestinal  viscera  are 
present  the  adhesions  are  separated  and  restitution  made.  The  contained 
omentum  is  ligated  and  removed  with  the  entire  sac  of  the  hernia. 

(4)  With  forceps  the  margins  of  the  ring  are  grasped  and  approximated 


GENERAL  SURGEEY  OF  THE  ABDOMEN 


349 


Whichever  way  the  overlapping  is  more  easy  of  accomplishment,  suggests  the 
direction  of  the  closure.  The  illustrations  show  the  overlapping  as  done  from 
above  downward. 


u. 


Hernia. 


Eepresents  the  hernial  ring  in  an  umbilical  hernia  laid  bare,  -with  the  tissues  dissected  back 
down  to  the  aponeurosis.  Two  fingers  of  one  hand  are  inserted  into  the  abdominal  cavity 
in  order  to  protect  the  intra-abdominal  organs  against  injury  from  the  needle,  which  is  inserted 
one  and  one-half  to  two  inches  from  the  edge  of  the  ring.  A  blunt  hook  is  inserted  on  either 
side  to  stretch  the  ring  transversely. 

(5)  For  this  approximation  an  incision  is  made  through  the  aponeurotic 
and  peritoneal  structures  of  the  ring  extending  one  inch  or  more  transversely 
to  each  side,  and  the  peritoneum  is  separated  from  the  under  surface  of  the 
upper  of  the  two  flaps  thus  formed. 


350 


GENERAL  SURGERY  OF  THE  ABDOMEN 


(6)  Beginning  from  one  to  one  and  one-half  inches  above  the  margin 
of  the  upper  flap,  three  to  four  chromicized  catgut  mattress  sutures  are  intro- 
duced, the  loop  firmly  grasping  the  upper  margin  of  the  lower  flap ;  sufficient 
traction  is  made   on  these  sutures  to   enable   peritoneal   approximation  Avith 


Umbilical  Hernia. 

Represents  three  chromicized  cat-gut  stitches  in  position.  The  cat-gut  is  represented 
double.  This  is  not  important,  but  has  the  advantage  of  extra  security  in  case  there  should 
be  a  defect  in  one  strand,  besides  making  it  possible  to  use  a  smaller  size  of  cat-gut. 


running  sutures  of  catgut.  The  mattress  sutures  are  then  drawn  into  position, 
sliding  the  entire  lower  flap  into  the  pocket  previously  formed  between  the 
aponeurosis  and  the  peritoneum  above. 

(7)     The  free  margin  of  the  upper  flap  is  fixed  by  catgut  sutures  to  the 
surface  of  the  aponeurosis  below,  and  the  superficial  incision  closed  in  the 


GENERAL  SURGERY  OF  THE  ABDOMEN 


351 


usual  manner.  The  lateral  approximation  is  carried  out  by  sliding  one  side 
under  the  other  in  the  same  manner.  In  the  larger  hernias  the  incision 
through  the  fibrous  covering  of  the  sac  may  be  made  somewhat  above  the 
base,  thereby  increasing  the  amount  of  tissue  to  be  used  in  the  overlapping 
process. 

We  have  employed  chromicized  catgut  sutures  in  place  of  the  silver  wire 
sutures  in  all  cases  operated  by  Mayo's  method.  Having  been  called  upon 
frequently  to  remove  silver  wire  sutures  which  other  surgeons  had  employed 


Mayo's  Operation  for  Uiibilical  Hernia. 


in  various  operations,  we  have  abandoned  their  use  entirely  and  found  that 
chromicized  catgut  has  all  of  the  good  qualities,  and  none  of  the  bad  ones  of 
silver  wire. 

The  plate  shows  the  manner  in  which  the  stitches  are  introduced,  the 
fingers  protecting  the  intra-abdominal  structures  against  injury  from  the 
needle. 

Another  plate  shows  the  deep  stitches  in  place,  which  when  tied  will  slide 
one  edge  of  the  ring  underneath  the  other.  The  line  of  sutures  should  extend 
transversely  across  the  body  instead  of  obliquely,  as  pictured  by  the  artist. 


352  GENERAL  SURGERY  OF  THE  ABDOMEN 

In  all  of  our  cases  we  have  found  it  possible  to  close  the  opening  without 
tension  by  placing  the  line  of  sutures  in  this  direction. 

In  small  hemige  three  deep,  and  about  five  superficial,  sutures  will  suffice, 
but  the  number  may  be  increased  according  to  the  size  of  the  opening. 

The  next  plate  shows  the  manner  in  which  the  overlapping  edge  of  the 
hernial  opening  is  sutured  to  the  aponeurosis. 

By  this  method  we  obtain  a  double  layer  of  the  strong  aponeurosis  com- 
posed of  the  fascia  of  the  external  and  internal  oblique  abdominal  muscles, 
together  with  the  transversalis  fascia. 

In  all  of  these  patients  we  have  observed  the  fact  that  they  have  a  sense 
of  security  and  strength  after  this  operation  which  none  formerly  had  after 
operations  for  the  relief  of  large  umbilical  hernia  by  other  methods. 

Important  points.  Having  dissected  out  the  entire  hernial  sac,  together 
with  its  overlying  thin  skin  down  to  the  edge  of  the  aponeurosis  forming  the 
hernial  ring,  we  must  plan  to  open  the  sac  and  dispose  of  its  contents. 

There  are  two  areas  in  which  the  omentum  is  usually  adherent  to  the  sac, 
one  opposite  the  most  superficial  portion,  the  other  along  the  edge  of  the 
hernial  ring. 

If  we  attempt  to  open  the  sac  opposite  either  of  these  points  we  will  find 
an  exceedingl.y  tedious  and  unsatisfactory  task.  It  is  quite  difiPerent  if  we 
open  the  sac  on  one  side  half-way  between  these  two  points,  where  the  surfaces 
are  usually  free  from  adhesions.  It  is  then  best  to  begin  at  one  point  and 
sj'stematicallj^  loosen  the  adhesions  between  the  omentum  and  the  hernial 
ring  until  the  former  is  entirely  free.  If  this  is  done  the  entire  task  can  be 
accomplished  in  a  few  minutes,  but  if  one  loosens  small  areas  here  and  there  in 
an  unsystematic  manner,  a  great  amount  of  time  may  be  unnecessarily  con- 
sumed to  the  detriment  of  the  patient. 

Should  the  sac  contain  intestines  still  greater  care  must  be  employed  for 
fear  of  causing  a  perforation.  Should  there  be  an  abrasion  on  the  surface  of 
the  intestine  this  should  be  covered  at  once  with  a  few  Lembert  sutures. 

Having  loosened  all  of  the  adhesions  between  the  omentum  and  the  hernial 
ring,  it  becomes  necessary  to  dispose  of  the  mass  of  omentum.  The  latter  is 
usually  so  matted  together  that  it  would  undoubtedh'  give  rise  to  great" dis- 
comfort from  pressure  were  it  to  be  returned  to  the  abdominal  cavity;  it  is 
consequently  best  to  ligate  it  in  a  number  of  portions,  to  cut  away  the  part 
that  has  been  matted  together,  and  return  the  remaining  portion  into  the 
abdominal  cavity.  At  this  point  it  is  important  to  observe  care  not  to  place 
the  ligatures  too  near  the  transverse  colon  for  fear  of  causing  necrosis. 

Prognosis.  If  this  plan  of  treatment  is  followed  the  prognosis  in  these 
cases  is  astonishingly  good,  both  as  regards  immediate  and  permanent  results. 

After-treatment.  It  is  well  to  avoid  all  abnormal  intra-abdominal  pressure 
(1)  by  reducing  the  obesity  by  means  of  diet  and  vigorous  exercise,  preferably 
walking;  (2)  by  avoiding  constipation;  (3)  by  regulating  the  diet  so  as  to 
avoid  gaseous  distension;  (4)  in  the  male  by  avoiding  obstruction  of  the 
urethra,  or  correcting  this  should  it  exist. 

Variation  of  incision.  Occasionally  one  will  find  a  small  umbilical  hernia 
in  a  patient  to  be  operated  for  some  other  intra-abdominal  condition,  like 
tumors  of  the  pelvic  organs,  appendicitis  or  gall-stones. 

If  the  incision  in  this  operation  is  to  be  in  the  median  line  it  is  best  to 
extend  it  above  the  umbilicus  a  distance  of  one  or  two  inches,  to  excise  the 
umbilicus  entirely,  to  split  the  fascia  of  the  recti  muscles  toward  the  median 
line  and  then  to  close  the  abdominal  wound  throughout  as  though  there  had 
been  no  hernia. 


GENERAL  SURGERY  OF  THE  ABDOMEN  353 

If  the  operation  is  for  the  removal  of  the  appendix  or  gall-stones  it  is  well 
to  make  the  incision  through  the  right  rectus  abdominis  muscles,  then  the 
inner  edge  of  the  abdominal  wall  can  be  everted.  If  there  is  adherent 
omentum  in  the  hernial  sac  this  can  be  peeled  out  and  then  a  purse-string 
suture  of  chromicized  catgut  passed  around  the  hernial  ring  with  a  short 
curved  needle  just  outside  of  the  abdominal  wall  and  tied  just  tightly  enough 
to  hold  the  edges  in  apposition.  A  second  similar  stitch  is  applied  just  within 
the  abdominal  wall  and  tied  in  the  same  manner. 

This  may  be  done  very  easily  except  in  patients  with  an  usually  thick 
abdominal  wall.  The  method  is,  however,  applicable  only  to  hernige  of 
moderate  size. 

VENTRAL  HERNIA  FOLLOWING  ABDOMINAL  SURGERY 

Type  of  case.  The  patient,  an  unmarried  woman  twenty-two  years  of  age,  an  office  girl 
by  occupation,  gives  the  following  history:  Uneventful  life  until  age  of  eighteen,  when  she 
had  an  acute  attack  of  appendicitis,  which  subsided  under  treatment  but  recurred  every  few 
months.  Two  years  ago  she  had  an  operation  for  the  relief  of  this  condition  at  the  end  of  an 
acute  attack.  The  wound  suppurated  and  healed  in  time  by  granulation.  The  patient  has 
been  free  from  acute  pain  since  that  time,  but  has  suffered  from  severe  gaseous  distension 
of  the  abdomen,  from  digestive  disturbances  and  from  constipation.  The  scar  began  to 
broaden  soon  after  the  patient  returned  to  her  work  and  shortly  afterwards  she  noticed  a 
distinct  bulging  of  the  abdominal  wall  at  the  point  of  the  scar.  This  portion  of  the  abdominal 
wall  has  become  constantly  thinner  and  the  bulging  has  increased. 

There  is  a  scar  ten  centimeters  in  length  and  five  centimeters  wide,  extending  parallel 
with  Poupart's  ligament  about  half-way  between  the  anterior  superior  spine  of  the  ilium  and 
the  umbilicus.  The  tissue  is  so  thin  that  the  motion  of  the  intestines  can  readily  be  distin- 
guished through  it.  Upon  pressing  the  fingers  against  this  tissue  one  may  readily  feel  a  definite 
ledge  composed  of  the  abdominal  muscles  on  either  side,  and  the  intestines  can  be  readily  felt 
behind  this  thin  structure.  There  is  a  strong  impulse  upon  coughing.  The  scar  is  very  tender 
upon  pressure. 

Etiology.  In  this  instance  there  had  been  an  abdominal  section  for  the 
removal  of  the  appendix.  The  incision  had  been  made  parallel  with  the  fibers 
of  the  external  oblique  abdominal  muscle,  then  it  had  been  carried  through 
the  internal  oblique,  the  transversalis  fascia  and  peritoneum. 

All  of  these  layers  had  been  united  after  the  operation,  but  the  suppuration 
which  followed  prevented  primary  union  and  consequently  there  was  a  union 
between  the  edges  of  all  the  layers  involved  on  each  side  of  the  line  of  incision 
and  the  edges  thus  formed  were  united  by  a  mass  of  cicatricial  tissue.  This 
is  the  least  stable  of  all  tissues  and  consequently  it  began  to  stretch  very  soon 
after  the  patient  left  her  bed,  becoming  more  and  more  thinned  out  from  day 
to  day  and  permitting  the  intra-abdominal  organs  to  protrude,  forming  a 
ventral  hernia. 

There  is  another  factor  in  this  case  which  favored  the  formation  of  a 
ventral  hernia.  The  incision  was  parallel  with  the  fibers  of  the  external  oblique 
abdominal  muscle  and  consequently  none  of  the  fibers  of  this  muscle  had  to 
be  severed,  as  they  were  simply  split  longitudinally.  Had  the  internal  oblique 
abdominal  muscle  been  likewise  split,  as  shown/ in  plate,  the  two  edges  would 
have  been  drawn  closely  together  as  a  result  of  their  own  contraction,  and 
the  lines  of  incision  through  the  two  muscular  layers,  being  at  right  angles 
to  each  other,  a  hernia  would  not  have  developed,  even  though  the  wound  had 
not  united  primarily. 

In  this  case  the  conditions  were  quite  different,  the  fibers  of  the  internal 
oblique  abdominal  muscle  being  cut  at  right  angles,  the  edges  of  the  wound 
were  drawn  farther  and  farther  apart  with  each  contraction  of  this  muscle 


354 


GENERAL  SURGERY  OF  THE  ABDOMEN 


as  soon  as  primary  union  of  the  cut  ends  became  impossible  on  account  of 
suppuration.  Moreover,  these  ends  became  adherent  to  the  edges  of  the 
wound  in  the  external  oblique  abdominal  muscle  and  overcame  the  tendency 
these  edges  naturally  show  to  remain  parallel  and  in  close  apposition. 


McBurney's  Incision. 


Eepresents  McBurney's  incision,  which  extends  parallel  with  the  fibres  of  the  external 
oblique  abdominal  muscle,  (a)  separating  its  fibres  without  cutting  them,  then  separating  the 
fibres  of  the  internal  oblique  muscle,  (b)  again  without  cutting  its  fibres  and  extending  through 
the  transversalis  fascia  and  peritoneum  (c)   in  the  same  direction. 


Indications  for  operation.  In  most  cases  of  ventral  hernia  following 
abdominal  section  there  is  no  definite  ring,  the  opening  being  wide;  there  is 
consequently  no  danger  from  strangulation.  There  is,  however,  the  constant 
feeling  of  insecurity  and  weakness  in  the  abdominal  wall  which  prevents  the 


GENERAL  SURGERY  OF  THE  ABDOMEN 


355 


patient  from  performing  the  duties,  or  indulging  in  the  pastimes,  of  persons  in 
health,  and  as  the  tissues  become  thinner  and  thinner,  there  is  really  some 
risk  of  having  them  give  way  entirely. 


Closure  of  Abdominal  Wound. 

Eepresents  the  manner  of  applying  sutures  in  closing  an  abdominal  incision  in  the  median 
line;  (a)  representing  the  deep  strong  fascia  composed  of  the  aponeurosis  of  the  external 
oblique  abdominal  muscles;  (b)  the  rectus  abdominis  muscle,  and  (c)  the  transversalis  fascia 
and  peritoneum. 

Moreover,  the  digestive  disturbances  of  which  such  patients  complain  are 
due  partly  to  the  fact  that  there  are  usually  adhesions  between  the  intestines 
and  omentum  and  the  scar  which  interfere  with  the  passage  of  food  and  gases 
through  the  portion  of  the  alimentary  canal  thus  impaired. 

When  the  protrusion  is  so  great  as  above  described,  and  cannot  be  com- 


356 


GENERAL  SURGERY  OF  THE  ABDOMEN 


fortably  retained  by  means  of  a  bandage,  there  is  a  sufficient  amount  of 
mechanical  obstruction  to  the  intestines  from  their  crowding  into  this  pouch 
to  account  for  the  digestive  disturbances.  For  these  reasons  it  seems  wise 
to  advise  operative  treatment,  especially  in  young  patients. 

Operative  technique.  We  first  make  an  incision  surrounding  all  of  the 
scar  tissue,  because  this  is  of  no  value  in  securing  a  permanent  cure  of  the 
hernia  and  its  removal  is  of  importance  from  a  cosmetic  standpoint. 

In  these  hernise,  as  in  umbilical,  the  adhesions  of  omentum  or  intestine 
are  likely  to  be  to  the  most  prominent  portion  of  the  hernial  protrusion  or 
to  the  edge  of  the  hernial  ring,  which  in  these  cases  is  so  large  as  scarcely 
to  deserve  this  name,  or  to  both  of  these  portions. 

The  operation  is  greatly  facilitated  by  making  the  incision  through  the 
peritoneum  at  a  point  where  there  are  no  adhesions.  This  may  usually  be 
accomplished  by  choosing  a  location  half-way  between  the  two  points  just 
mentioned. 

A  further  aid  is  found  in  lifting  up  the  tissues  with  two  dissecting  forceps, 


Abdominal  Wall,  Upper  Three-Fourths. 

a  skin;  b  fat;  c  external  oblique  abdominal  muscle;  d  internal  oblique  abdominal  muscle; 
e  transversalis  fascia;  /  peritoneum;  g  linea  alba;  i  rectus  abdominis  muscle.  The  ajjoneurosis 
is  divided  into  an  external  and  an  internal  layer,  the  former  passing  in  front,  the  latter 
behind  the  rectus  abdominis  muscle. 


one  in  the  hand  of  an  assistant,  the  other  in  the  surgeon's  hand,  and  cutting 
between. 

As  soon  as  the  peritoneal  cavity  has  been  opened,  all  adhesions  are  care- 
fully separated  in  a  systematic  manner.  If  abrasion  occurs  upon  the  serous 
surface  of  an  intestine  this  is  at  once  covered  with  one  or  more  Lembert 
stitches.  Should  the  omentum  be  matted  together  or  appear  in  irregular 
bunches  or  strands  these  are  ligated  and  cut  away.  Then  the  intestines  and 
omentum  are  replaced  into  the  abdominal  cavity  and  covered  with  a  broad 
pad  of  sterilized  gauze,  moistened  with  warm  normal  salt  solution. 

It  now  becomes  necessary  to  make  a  careful  dissection  of  the  edges  of  the 
wound,  in  order  to  lay  bare  each  one  of  the  layers  of  tissue.  This  is  possible 
even  in  cases  in  which  the  hernia  has  existed  for  a  number  of  years. 

We  first  come  to  the  edges  of  the  incision  in  the  external  oblique  abdominal 
muscle  and  its  fascia,  then  we  encounter  the  fibers  of  the  internal  oblique,  cut 
at  right  angles  and  greatly  retracted,  and  lastly  upon  the  transversalis  fascia 
and  peritoneum  combined.  We  have  found  that  a  hernia  in  which  all  the 
layers  have  been  carefully  dissected  out  in  this  manner  may  be  closed  with 
the  same  degree  of  certainty,  as  regards  permanency  of  cure,  as  an  ordinary 
laparotomy  wound. 


GENERAL  SURGERY  OF  THE  ABDOMEN  • 


357 


A  row  of  silkworm  gut  sutures  is  now  inserted,  but  not  tied.  The  stitches 
are  placed  about  three-fourths  of  an  inch  apart  and  grasp  each  layer  down  to, 
but  not  through,  the  peritoneum.  In  this  case  we  take  especial  care  to  draw 
the  internal  oblique  abdominal  muscle  forward  with  dissecting  forceps  in 
order  to  secure  a  deep  bite.  Each  layer  is  then  sutured  separately  with  a 
continuous  catgut  stitch.  For  this  purpose  we  prefer  to  utilize  fine  chromi- 
cized  catgut,  No.  1,  threaded  double.  This  gives  the  suture  the  same  strength 
as  a  heavier  catgut  used  single  and  has  the  advantage  that  it  does  not  twist 
nor  become  unthreaded,  and,  theoretically  at  least,  it  offers  more  favorable 
conditions  for  absorption  when  it  has  accomplished  its  purpose. 


Diagram   Showing  Abdominal   Section   in   Median   Line   in   Upper    Three-Fourths   of 

Abdominal  Wall. 

a  skin;  6  fat;  c  aponeurosis  of  external  oblique  abdominal  muscle;  d  aponeurosis  of 
internal  oblique  abdominal  muscde,  divided,  the  upper  half  passing-  with  the  aponeurosis  of  the 
external  oblique  in  front  of  the  rectus  abdominis  muscle  (i)  the  lower  half  joining  the  trans- 
versalis  fascia  and  passing  behind  the  rectus  abdominis  muscle;  e  transversalis  fascia;  /  peri- 
toneum; g  line  of  incision.  The  lower  layer  of  the  aponeurosis  of  the  internal  oblique  abdominis 
muscle;  the  transversalis  fascia  and  the  peritoneum  are  usually  very  closely  united,  although 
they  can  usually  be  easily  separated  in  the  absence  of  inflammatory  processes. 


After  each  layer  has  been  sutured  carefully,  the  silkworm  gut  sutures  are 
tied  over  all.  We  believe  that  it  is  most  important  never  to  draw  any  of  these 
stitches  too  tightly  for  fear  of  causing  pressure-necrosis. 

A  narrow  pad  of  sterile  gauze  is  laid  upon  the  wound  and  then  the  ab- 
dominal wall  is  supported  with  tAvo  straps  of  rubber  adhesive  plaster,  at  least 
two  inches  wide,  in  order  to  relieve  the  tension  upon  the  sutures. 

Principles  of  cure.  It  does  not  matter  in  what  portion  of  the  abdominal 
wall  the  ventral  hernia  following  an  abdominal  section  may  occur,  the  prin- 
ciples concerned  in  its  closure  are  always  the  same.  The  cicatricial  tissue  is 
carefully  excised,  the  different  anatomical  layers  are  dissected  out  and  then 
united  with  deep  silkworm  gut  sutures,  while  each  layer  is  united  separately 
with  buried  sutures  of  chromicized  catgut  which  may  be  applied  in  continued 
or  interrupted  form. 


358 


GENERAL  SURGERY  OF  THE  ABDOMEN 


As  most  of  these  hernia  occur  either  after  appendicitis  operations  in  the 
right  inguinal  region,  or  in  the  median  line  between  the  umbilicus  and  the 
pubis,  we  also  illustrate  the  operation  in  the  latter  variety. 

In  this  position  our  dissection  must  expose  the  deep  fascia  composed  of  the 
aponeurosis  of  the  external  and  internal  oblique  abdominal  muscles,  the 
rectus  abdominis  muscle  on  either  side  and  the  transversalis  fascia  and  peri- 
toneum which  are  closely  united. 

In  the  plate  these  layers  are  shown,  the  silkworm  gut  stitches  being  in 
place  but  not  tied.  The  peritoneum  and  transversalis  fascia  have  been  united 
by  means  of  a  continuous  catgut  suture  passing  over  the  silkworm  gut  sutures 


Abdominal  'JVall  in  Lower  One-Fourth  of  Distance  Between  Sternum  and  Pubis. 

Showing  the  entire  aponeurosis  of  the  internal  oblique  abdominal  muscle  extending  in 
front  of  the  rectus  abdominis  muscle  {d)  together  with  the  aponeurosis  of  the  external 
oblique  (c).  All  sutures  are  in  place,  the  silkworm  gut  suture  extending  through  all  layers 
down  to,  but  not  through,  the  peritoneum  (/)  the  rectus  muscle  (i)  and  the  aponeurosis  of  the 
internal  {d)  external  (c)  oblique,  each  being  sutured  separately  with  catgut. 


SO  that  the  latter  when  tied  will  bring  up  the  peritoneum  and  thus  prevent 
the  formation  of  dead  spaces  between  this  and  the  posterior  surface  of  the 
recti-muscles. 

The  interrupted  stitches  have  been  passed  through  the  recti  muscles  in  the 
upper  part  of  the  wound  and  tied  and  two  others  have  been  inserted  in  the 
lower  part  of  the  wound  and  left  untied  in  order  to  show  the  deeper  stitches. 

The  deep  fascia,  composed  of  the  aponeurosis  of  the  internal  and  external 
oblique  abdominal  muscle,  which  is  the  most  important  layer,  will  be  carefully 
sutured  over  this,  as  shown,  and  then  the  deep  silkworm  gut  sutures  will  be 
tied  and  a  row  of  superficial  sutures  applied  for  coaptation  of  the  skin. 

A  similar  dressing  will  be  applied  as  described  above  and  the  abdominal 
walls  will  be  supported  with  rubber  adhesive  plaster  as  before. 


GENERAL  SURGERY  OF  THE  ABDO'Mi^N  359 

HERNIA  OF  THE  LINEA  ALBA 

Typical  case.  A  gardener  by  occupation,  forty-six  years  of  age,  gives  the  following 
history:  He  has  always  been  in  good  health,  with  the  excexjtion  of  having  had  an  attack  of 
mountain  fever  lasting  ten  weelvs,  from  which  he  suffered  many  years  ago. 

He  does  not  remember  having  suffered  any  injury,  but  he  has  had  a  number  of  periods  of 
intoxication  lasting  for  several  days  at  a  time,  during  which  he  might  easily  have  sustained 
some  injury  without  knowing  it.  Six  years  ago  he  noticed  a  small  swelling  in  the  median  line 
half-way  between  the  end  of  the  sternum  and  the  umbilicus.  This  has  increased  steadily  until 
it  has  attained  the  size  of  a  hen's  egg.  Usually  he  has  had  simply  a  feeling  of  weight  in  this 
swelling,  but  occasionally  it  is  quite  painful  for  several  days.  There  is  a  slight  decrease  in  the 
size  of  the  swelling  at  night  and  a  slight  increase  when  working  hard. 

Patient  is  well  nourished,  thoracic  and  abdominal  organs  normal,  appetite  good,  bowels 
constipated.  Two  inches  above  the  umbilicus,  in  the  median  line,  there  is  a  swelling  as  large 
as  a  hen 's  egg,  not  painful  on  pressure,  semi-fluctuating,  no  impulse  upon  coughing,  not 
reducible  upon  pressure.  In  all  other  respects  the  physical  examination  has  resulted 
negatively. 

Judging  from  the  consistency  of  the  tumor,  from  its  oval,  slightly  lobu- 
lated  form,  and  its  subcutaneous  location,  it  is  likely  that  it  is  composed  of 
fatty  tissue.  It  may  consequently  be  a  lipoma.  "Were  there  a  history  of 
traumatism  immediately  preceding  its  appearance,  or  were  there  an  impulse 
upon  coughing,  we  could  make  a  positive  diagnosis  of  a  hernia  of  the  linea 
alba. 

Differential  diagnosis.  There  are  certain  peculiarities  in  this  case  which 
point  distinctly  to  the  latter  diagnosis : 

(1)  There  has  been  a  disturbance  of  the  stomach  since  the  appearance 
of  the  swelling,  which  is  due  in  many  cases  of  hernia  of  the  linea  alba  to  the 
fact  that  the  adherent  omentum  interferes  with  the  normal  motility  of  the 
stomach.  The  opening  in  the  linea  alba  is  frequently  so  small  that  an  impulse 
upon  coughing  is  not  possible.  This  is  still  further  interfered  with  by  the 
extensive  adhesions  of  the  omentum  to  the  hernial  sac,  Avhich  is  frequently 
not  a  true  sac  composed  of  peritoneum  and  transversalis  fascia,  but  simply 
a  space  in  the  ruptured, tissues.  This  disturbance  is  sometimes  so  great  that 
the  patient  is  entirely  disabled. 

(2)  The  tumor  varies  in  size,  decreasing  a  little  at  night  and  increasing 
perceptibly  upon  making  severe  exertion  for  a  considerable  time,  as  upon 
working  very  hard.  Although  there  is  no  impulse  upon  coughing  or  straining 
it  seems  that  more  of  the  tissue  of  the  omentum  becomes  forced  through  the 
small  hernial  opening  when  there  is  long-continued  abnormal  intra-abdominal 
pressure  than  when  this  is  normal. 

(3)  The  swelling  becomes  painful  at  irregular  intervals,  especially  when 
the  patient  engages  in  hard  work.  We  have  repeatedly  seen  strong,  other- 
wise perfectly  healthy  men  entirely  disabled  for  work  by  the  pain  resulting 
from  a  hernia  in  this  region,  so  small  that  it  had  escaped  the  notice  of  phy- 
sicians and  surgeons  for  years,  the  patient  not  taking  it  to  be  of  sufficient 
importance  to  require  their  attention. 

(4)  The  swelling  usually  appears  suddenly  after  an  injury,  such  as  a 
sharp  blow  upon  the  linea  alba. 

Considering  all  of  these  facts  it  seems  likely  that  this  is  a  hernia  of  the 
linea  alba,  although  we  cannot  be  absolutely  positive  in  our  diagnosis  until 
the  mass  has  been  exposed. 

Etiology.  In  this  case  the  etiology  is  not  very  clear  on  account  of  the  fact 
that  it  is  likely  the  patient's  powers  of  observation  were  greatly  impaired  at 
the  time  at  which  the  condition  was  produced. 

Indications  for  operation.  The  amount  of  suffering  is  not  sufficient  to 
disable  the  patient  from  performing  his  work,  but  he  suffers  from  gastric 
disturbances  and  from  pain  in  the  region  of  the  swelling  whenever  he  labors 


360  GENERAL  SURGERY  OF  THE  ABDOMEN 

hard,  and  the  periods  of  acute  irritation  are  becoming  more  numerous,  and 
the  extent  of  the  irritation  more  severe  constantly.  Moreover,  the  swelling 
is  becoming  more  and  more  sensitive  to  pressure  from  the  clothing. 

Were  it  possible  to  reduce  this  swelling  into  the  abdominal  cavity  its 
retention  by  means  of  a  truss  might  be  considered,  but  experience  has  shown 
that  this  would  not  succeed. 

The  patient  is  not  in  any  immediate  danger,  because  the  opening  is  too 
high  in  the  median  line  to  permit  the  protrusion  of  a  portion  of  the  small 
intestine,  and  it  is  too  small  to  engage  either  the  stomach  or  the  transverse 
colon.    There  is  consequently  no  danger  of  strangulation. 

The  patient  is  familiar  with  all  of  these  facts  and  has  chosen  the  operation 
for  the  purpose  of  securing  relief  from  pain  and  to  increase  his  working 
capacity. 

The  preparatory  treatment  is  the  same  as  in  all  abdominal  sections.  Were 
the  patient  very  obese,  we  would  advise  treatment  for  the  relief  of  this 
encumbrance. 

Operative  technique.  A  longitudinal  incision  twelve  centimeters  in  length 
is  made  over  the  most  prominent  portion  of  the  swelling,  through  the  skin 
and  superficial  fascia,  which  exposes  a  flattened,  oval  mass  as  large  as  a  hen's 
egg.  Lifting  up  the  edges  of  this  mass  the  finger  reaches  a  point  in  the 
aponeurosis  forming  the  linea  alba  which  is  defective.  At  this  point  the  latter 
has  a  perforation  which  would  admit  two  fingers  were  it  not  occupied  by  a 
projection  of  the  fatty  swelling  which  we  have  exposed.  The  latter  is  lobu- 
lated,  quite  vascular  and  is  slightly  adherent  to  the  surrounding  tissues.  It 
is  not  surrounded  by  a  true  hernial  sac.  It  has  consequently  come  through 
in  the  defect  in  the  abdominal  wall  and  we  have  before  us  a  hernia  of  the 
linea  alba,  and  the  fatty  mass  is  composed  of  omentum  which  has  been  forced 
out  of  the  peritoneal  cavity  through  this  opening. 

It  is  impossible  to  replace  the  omentum  into  the  peritoneal  cavity,  and  if 
it  were  it  would  not  be  desirable  to  do  so  because  it  has  been  so  completely 
changed  from  a  thin,  delicate,  protecting  sheet  into  a  clumsy  mass,  that  it 
would  probably  give  rise  to  irritation  were  it  replaced.  We  will  consequently 
transfix  the  narrowed  portion,  at  the  point  where  it  issues  from  the  opening 
in  the  aponeurosis,  with  a  double  catgut  ligature,  tie  it  in  halves,  cut  away 
the  mass  a  sufficient  distance  outside  of  the  ligature  to  prevent  slipping,  and 
drop  the  stump  into  the  abdominal  cavity. 

It  frequently  happens  that  the  fat  contained  in  a  hernia  of  the  linea  alba 
is  partly  or  entirely  composed  of  pre-peritoneal  fat  instead  of  omentum.  These 
patients  sutt'er  even  greater  pain  than  those  in  which  the  mass  is  composed 
entirely  of  omentum.  When  this  mass  is  removed  the  pedicle  is  simply  reduced 
through  the  hernial  opening  into  the  pre-peritoneal  space. 

The  remaining  steps  of  the  operation  vary  according  to  the  character  of 
the  opening.  If  this  is  small  and  circular,  and  if  its  edges  are  thick,  it  is 
probably  quite  as  unnecessary  to  do  anything  toward  closing  it  as  in  femoral 
hernia.    As  soon  as  the  ring  is  empty  it  will  close  spontaneously. 

If  the  opening  is  oblong  or  triangular  in  form  but  not  more  than  two 
or  three  centimeters  in  length  with  substantial  edges,  these  may  be  brought 
together  with  two  or  three  buried,  chromicized  catgut  sutures.  If,  however, 
the  opening  is  oblong  and  its  edges  thin,  as  in  this  case,  it  is  likely  there 
would  be  a  recurrence  unless  the  defect  were  repaired  in  a  more  substantial 
manner. 

In  order  to  secure  favorable  conditions  for  a  permanent  cure  in  these 
cases  it  is  necessary  to  carefully  expose  each  one  of  the  various  layers  com- 
posing the  abdominal  wall  at  this  point  and  then  to  close  the  wound  precisely 
in  the  manner  described  in  operations  for  ventral  hernia  following  abdominal 


GENERAL  SURGERY  OF  THE  ABDOMEN 


361 


section  in  the  median  line.  The  anatomical  layers  in  this  portion  of  the  linea 
alba  from  without  inward  are  as  follows:  1,  skin;  2,  superficial  fascia;  3,  fat; 
4,  strong  fascia  composed  of  the  aponeurosis  of  the  external  oblique  abdom- 
inal muscle  and  tho  outer  half  of  the  fascia  of  the  internal  oblique;  5,  rectus 


Closure  of  Abdominal  Wound. 

Eepresents  the  deep  silkworm  gut  sutures  tied  loosely  so  as  to  avoid  pressure  necrosis  and 
a  continuous  coaptation  stitch  for  the  accurate  adjustment  of  the  edges  of  the  skin. 

abdominis  muscle;  6,  the  inner  half  of  the  fascia  of  the  internal  oblique 
abdominal  muscle;  7,  the  transversalis  fascia j  8,  peritoneum.  The  last  three 
layers  mentioned  are  usually  so  closely  united  with  each  other  that  they 
appear  as  one. 

Having  exposed  these  layers  we  close  the  wound  as  shown  heretofore. 

A  row  of  silkworm  gut  sutures  extending  through  all  the  layers  down  to 


362  GENERAL  SURGERY  OF  THE  ABDOMEN 

the  peritoneum  are  inserted  but  not  tied.  Then  the  deepest  layer  composed 
of  peritoneum,  transversalis  fascia  and  the  inner  half  of  the  aponeurosis  of 
the  internal  oblique  abdominal  muscle  is  sutured  with  a  continuous  catgut 
suture.  Now  the  recti  muscles  are  brought  together  by  means  of  just  a  suffi- 
cient number  of  interrupted  catgut  sutures  to  bring  them  in  accurate  appo- 
sition. The  strong,  deep  fascia,  upon  which  the  permanency  of  the  cure  really 
depends,  is  next  carefully  sutured  with  chromicized  catgut ;  and  then  the 
deep  silkworm  gut  sutures  are  tied  and,  if  necessary,  a  row  of  coaptation 
stitches  is  applied  to  adjust  the  edges  of  the  skin. 

In  connection  with  this  case  we  wish  to  direct  attention  particularly  to 
the  diagnosis  of  these  troubles. 

They  are  somewhat  rare  and  almost  never  diagnosed  until  they  have 
suffered  for  many  years.  In  the  meantime  they  usually  go  from  one  physician 
to  another,  receiving  treatment  alternately  for  the  relief  of  gastric  dis- 
turbances and  neurasthenia. 

HERNIA  IN  CHILDREN 

Example.  A  boy,  twenty  months  of  age,  comes  with  the  following  history :  He  has  always 
been  well  and  strong  since  birth  and  none  of  his  functions  has  been  impaired.  There  is  a 
vague  history  of  a  fall  two  months  ago,  but  nothing  definite  can  be  determined  in  this  respect. 
It  is  quite  likely  that  the  mother  imagines  this  from  the  fact  that  she  feels  compelled  to  account 
for  the  child 's  condition  in  some  way. 

Six  months  ago  the  mother  noticed  a  swelling  in  the  region  of  the  left  inguinal  canal 
extending  into  the  scrotum  on  that  side.  This  swelling  decreases  in  size  when  the  child  is  in 
bed,  but  cannot  be  reduced  while  he  is  awake.  The  protrusion  increases  when  the  child  cries. 
There  is  an  abundance  of  fat  in  the  subcutaneous  tissues  and  it  is  difficult  to  determine 
whether  the  mass  fluctuates  upon  palpation.  An  attempt  has  been  made  to  apply  a  truss,  but 
the  child  screamed  incessantly  when  this  was  in  place,  so  that  it  had  to  be  removed  directly. 
The  child  is  otherwise  normal,  with  the  exception  of  having  an  adherent  prepuce. 

Differential  diagnosis.  It  is  often  difficult  to  make  a  positive  diagnosis 
in  a  child  so  young  as  this  one,  because  it  is  practically  impossible  to  keep  him 
quiet  long  enough  to  determine  the  conditions  present,  unless  he  is  anes- 
thetized. 

Hydrocele  is  the  only  condition,  aside  from  hernia,  which  is  common  in 
children  of  this  age  causing  a  swelling  in  this  position.  In  one  case  we  en- 
countered a  lymphangioma,  and  a  congenital  lipoma,  or  one  developing  shortly 
after  birth,  which  is  possible  in  this  location,  but  so  rare  that  it  really  need 
not  be  considered. 

Now  that  the  child  is  anesthetized,  we  find  that  the  swelling  can  be  re- 
duced into  the  abdominal  cavity  through  the  inguinal  canal,  but  as  soon  as 
the  pressure  is  released  it  reappears  at  once.  There  is  also  the  sensation  to 
touch  of  reducing  a  mass  of  a  definite,  permanent  form  which  would  not  be 
the  case  were  the  swelling  composed  of  omentum  or  intestine  contained  in  a 
hernial  sac.  The  condition  present  must  consequently  be  an  irreducible 
hydrocele  of  the  cord. 

Etiology.  In  this  patient  the  communication  between  the  peritoneal  cavity 
and  the  tunica  vaginalis  evidently  remained  open  after  the  descent  of  the 
testicle  and  gave  rise  to  a  congenital  hernia.  At  some  time  later  the  upper 
end  of  this  hernial  sac  closed  by  adhesion  of  its  walls,  and  then  its  serous 
lining,  instead  of  becoming  adherent  to  the  tissues  of  the  spermatic  cord  and 
thus  bringing  about  a  spontaneous  cure,  secreted  fluid  and  this  caused  the 
distension  of  this  sac.  Being  located  in  the  inguinal  canal  the  latter  cannot 
close,  hence  the  impulse  upon  coughing  or  straining. 

Indications  for  operation.  So  long  as  the  inguinal  canal  is  distended  by 
this  pouch  filled  with  fluid  it  is  impossible  for  it  to  close  and  the  development 


GENERAL  SURGERY  OF  THE  ABDOMEN  363 

of  the  child  cannot  proceed  normally.  The  mass  cannot  be  reduced  into  the 
peritoneal  cavity  thus  leaving  the  canal  free  to  close,  neither  can  it  be  with- 
drawn downward.  It  is  consequently  necessary  to  resort  to  some  operative 
measure  for  the  relief  of  the  condition.  This  can  be  accomplished  by  with- 
drawing the  fluid  by  means  of  a  canula,  but  this  would  probably  not  secure 
permanent  relief  because  the  serous  fluid  would  re-form  unless  some  irritating 
substance  was  injected  which  would  result  in  a  sufficient  amount  of  aseptic 
inflammation  to  cause  the  surfaces  to  adhere.  For  this  purpose  a  few  drops 
of  ninety-flve  per  cent,  solution  of  carbolic  acid  has  been  injected,  or  a  larger 
quantity  of  flve  per  cent,  solution  of  the  same  substance,  or  a  few  drops 
of  tincture  of  iodine.  None  of  these  substances  is,  however,  certain  to  accom- 
plish the  end  desired  and  none  of  them  entirely  harmless.  We  will  conse- 
quently choose  a  method  which  is  not  connected  with  more  danger  and  which 
will  result  in  a  permanent  cure. 

Technique  of  operation.  An  incision  is  made  over  the  most  prominent 
portion  of  the  swelling  parallel  with  the  inguinal  canal  and  down  to  the  her- 
nial sac.  It  is  now  apparent  that  the  sac  is  distended  with  fluid.  We  incise 
it  and  permit  the  fluid  to  escape.  We  find  a  smooth  sac  containing  nothing 
but  about  thirty  cubic  centimeters  of  a  clear  fluid.  The  sac  is  easily  separated 
from  the  surrounding  tissues.  At  its  upper  end  it  is  found  closed  by  means 
of  scar  tissue  which  has  united  its  walls.  It  is  withdrawn  from  the  inguinal 
canal  a  little  further,  then  transfixed  with  a  needle  threaded  with  catgut  and 
tied.  Then  the  sac  is  cut  away,  care  being  taken  to  leave  a  sufficient  amount 
of  tissue  beyond  the  ligature  to  prevent  slipping.  The  stump  is  permitted  to 
retract  within  the  abdominal  cavity.  No  attempt  is  made  to  close  the  inguinal 
canal,  because  this  occurs  spontaneously  in  children  as  soon  as  the  sac  is 
removed.    Suturing  the  skin  completes  the  operation. 

Carefully  compiled  statistics  have  shovv^n  that  of  all  the  hernije  encountered 
in  the  adult  less  than  five  per  cent,  have  existed  since  childhood,  and  also 
that  of  all  children  under  six  years  of  age  suffering  from  hernia  seventy-three 
per  cent,  will  heal  spontaneously,  without  any  form  of  treatment,  before  the 
age  of  thirteen,  consequently  the  relative  number  of  hernise  in  children  re- 
quiring operative  treatment  must  be  very  small. 

Conditions  favoring  spontaneous  cure.  Spontaneous  cure  is  accomplished. 
(1)  By  the  late  closure  of  the  inguinal  canal,  which  should  have  occurred 
before  birth;  (2)  By  the  broadening  of  the  pelvis.  The  parietal  peritoneum 
enlarges  at  the  expense  of  the  mesentery;  the  latter  being  thus  shortened 
prevents  the  entrance  of  the  intestines  into  the  inguinal  canal;  (3)  By  the 
displacement  of  the  internal  abdominal  ring  with  the  growth  of  the  child; 
(4)AVith  the  growth  of  the  child  a  number  of  the  predisposing  causes  are 
eliminated. 

Predisposing-  conditions  to  overcome,  (a.)  Abnormal  intra-abdominal 
pressure. — There  can  be  no  doubt  that  the  most  important  direct  cause  of 
herniae  in  children  is  an  abnormal  intra-abdominal  pressure.  This  may  be  due : 
1,  To  gaseous  distension  of  the  stomach  and  bowels,  caused  by  faulty  feeding 
and  consequent  indigestion;  2,  To  great  pressure  exerted  during  the  act  of 
defecation,  on  account  of  constipation;  3,  To  the  same  condition  due  to 
obstruction  on  account  of  phimosis ;  4,  To  severe  vomiting ;  5,  To  long-con- 
tinued coughing.  In  connection  with  all  of  these  conditions,  it  is  to  be  re- 
membered that  children  with  digestive  disturbances  necessarily  suffer  much 
from  pain,  and  the  exertion  incident  to  crying  will  greatly  increase  the 
existing  abnormal  intra-abdominal  pressure.  In  order  to  quiet  the  child  the 
mother  will  nurse  it  at  irregular  intervals  and  this  will  again  increase  the 
digestive  disorder,  and  this,  in  turn,  the  intra-abdominal  pressure  and  pain. 

(b.)     Increased  intra-abdominal  pressure   due   to   coughing. — We   have   ob- 


364  GENERAL  SURGERY  OF  THE  ABDOMEN 

served  cases  in  which  the  hernige  healed  regularly  during  the  summer  months, 
but  reappeared  in  the  autumn  as  soon  as  the  children  acquired  coughs,  which 
lasted  almost  all  winter.  By  the  time  spring  arrived  the  herniie  had  attained 
considerable  size,  only  to  heal  again  during  the  summer  while  the  patients 
were  free  from  coughs.  By  placing  these  children  in  bed  and  elevating  the 
lower  end  sufficiently  to  make  an  angle  of  twenty  degrees  and  giving  them 
remedies  to  relieve  the  cough,  the  hernias  disappeared  within  six  weeks.  Then 
advising  the  mothers  to  give  the  children  cold  baths  every  day  and  to  bring 
them  for  inspection  often  enough  to  keep  the  condition  under  control,  and 
giving  them  codliver  oil  and  malt  extract  as  soon  as  the  cold  weather  ap- 
peared, they  went  through  the  next  winter  without  coughs  and  consequently 
without  a  recurrence  of  the  herniie.  In  the  same  manner  children  who  are 
suffering  from  obstruction  to  the  upper  air-passages,  on  account  of  enlarged 
tonsils,  nasal  adenoids  or  polypi  and  consequent  conditions,  will  rapidly 
recover  from  their  hernia;  if  these  conditions  are  relieved  by  proper  treatment. 

(c.)  Increased  pressure  due  to  gaseous  distension. — It  is  very  usual  for 
the  children  who  are  brought  into  the  hospitals  for  the  treatment  of  hernia 
to  have  greatly  distended  abdomens  due  to  digestive  disorders  resulting  in 
gaseous  distension  of  the  stomach  and  intestines.  If  this  occurs  in  nursing 
infants  the  mother  should  be  instructed  to  nurse  the  child  at  regular  times. 
Her  own  habits  and  diet  should  also  be  regulated.  If  the  child  is  constipated 
this  condition  should  be  relieved.  Aside  from  this  the  mother  must  be  in- 
structed never  to  carry  the  child,  because  she  will  not  follow  the  advice  of 
keeping  it  in  the  inverted  position,  and,  consequently,  will  increase  the  intra- 
abdominal pressure  whenever  she  picks  up  the  infant.  It  should  sleep  in  a 
separate  bed  with  the  lower  end  elevated  sufficiently  to  make  an  angle  with  the 
floor  of  about  twenty  or  thirty  degrees.  This  will  keep  the  hernial  sac  empty  of 
intestines  and  omentum  and  will  very  greatly  assist  in  the  obliteration  of  the 
hernia.  If  the  mother's  milk  continues  to  give  rise  to  indigestion,  notwith- 
standing every  precaution  available  for  making  it  wholesome,  it  is  often  best 
to  place  the  child  partly  or  wholly  on  artificial  food,  at  least  for  a  time.  Above 
all  things,  however,  it  is  important  to  impress  the  mother  with  the  necessity 
of  being  regular  in  feeding  the  child  and  to  again  place  it  in  its  bed  as  soon 
as  it  has  been  nourished,  or,  better  still,  to  lean  over  the  child's  bed  and  nurse  it 
without  disturbing  its  partly  inverted  position. 

We  have  repeatedly  placed  these  children  in  the  hospital  and  sent  the 
mother,  who  was  exhausted  from  overwork  and  care  of  the  sick  child,  home 
to  rest,  permitting  her  to  come  to  the  hospital  morning,  noon  and  night  to 
nurse  the  child.  After  the  first  day  or  two  the  mother  becomes  rested,  her 
journey  to  and  from  the  hospital  compel  her  to  be  out  of  doors,  and  the 
fact  that  she  is  relieved  of  the  care  of  the  child  gives  her  the  necessary  rest 
and  sleep.  In  the  meantime  her  milk  improves,  the  child  becomes  accus- 
tomed to  lie  quietly  in  bed  and  to  take  its  nourishment  regularly,  its  digestion 
improves,  the  gaseous  distension  disappears,  and  with  it  the  abnormal  intra- 
abdominal pressure,  which  is  still  further  relieved  because  the  child  sleeps 
most  of  the  time  and  seldom  cries.  After  the  child  has  been  in  the  partly 
inverted  position  for  a  few  days  the  hernial  sac  remains  empty  so  long  as 
this  position  is  continued,  even  if  he  strains  and  cries. 

(d.)  Increased  intra-ahdominal  pressure  during  defecation,  due  to  con- 
stipation.— Children  suffering  from  hernia  should  not  be  allowed  to  become 
constipated,  because  the  increased  intra-abdominal  pressure  necessary  to 
accomplish  the  evacuation  of  the  bowels  in  constipation  is  in  itself  sufficient  to 
prevent  a  hernial  aperture  from  closing.  This  is  one  of  the  most  common 
causes  of  hernia  in  children,  and  one  of  the  easiest  to  be  eliminated. 

(e.)     Increased  intra-abdominal  pressure  due  to  obstruction  to  the  passage 


GENERAL  SURGERY  OF  THE  ABDOMEN 


365 


Congenital  Oblique  Inguinal  Hernia  in  a  Child  of  Eleven  Months. 

StrangTilatioii  Irreducible.  Treatment — Herniotomy.  Loop  of  Ileum  Twisted  at  the 
Hernial  Ring.  Color  of  Bowel  Copf)ery-Eed.  Bowel  Irreducible  Until  the  Hernial  Ring  Was 
Incised.     Closure  by  Imbrication. 


Congenital  Oblique  Inguinal  Hernia  and  Hydrocele  of  the  Cord  in  a  Boy  4%  Years  of 
Age.     Treatment — HEKNioTOiiY  and  Obliteration  of  Both  Sacs. 


366  GENERAL  SURGERY  OF  THE  ABDOMEN 

of  urine  as  a  result  of  phimosis. — That  phimosis  is  a  frequent  cause  of  hernia  in 
children  is  plain  from  the  fact  of  the  greater  frequency  of  umbilical  hernia 
in  male  than  in  female  children.  The  greater  frequency  of  inguinal  hernia  in 
male  children  can  readily  be  accounted  for  by  the  difference  in  the  anatomic 
structures,  but  this  is  not  the  case  in  umbilical  hernia?,  which  is  also  shown 
statistically  to  be  more  common  in  male  than  in  female  children.  It  has 
lately  been  suggested  that  phimosis  cannot  be  an  important  cause  of  hernia 
in  children,  because  if  this  were  the  case  the  Jewish  nation  must  necessarily 
be  much  freer  from  hernia  than  others.  This  is,  however,  not  the  case.  In 
fact,  it  has  been  shown  by  statistics,  especially  in  Russia,  that  at  the  age  of 
twenty  to  twenty-one  proportionally  more  Jews  than  Christians  are  afflicted 
with  hernia.  This,  however,  may  be  explained  by  the  fact  that  the  Jews  are 
more  subject  to  hereditary  diseases  of  all  kinds,  on  account  of  the  system 
of  intermarriage  in  families. 

If  the  phimosis  is  relieved,  either  by  circumcision  or  by  dilatation  of  the 
prepuce,  and  the  child  kept  in  bed  for  four  to  six  weeks  with  the  foot  of  the 
bed  elevated,  the  hernia  will  almost  invariably  be  cured.  During  the  same 
time  the  diet  and  the  bowels  must  be  carefully  regulated,  and  it  is  doubtful 
Avhicli  of  these  three  means  has  been  of  the  greatest  importance  in  producing 
a  cure.  It  is  surprising  how  rapidly  the  opening  will  contract  under  these 
conditions.  IMoreover,  during  this  time  the  patient  acquires  regular  habits 
which  may  afterwards  be  easily  maintained  if  their  importance  is  explained 
to  the  mother,  and  especially  if  it  is  impressed  on  her  that  by  following  the 
directions,  which  will  naturally  appeal  to  her  on  account  of  their  simplicity 
and  reasonableness,  she  will  be  able  to  make  operative  treatment  unnecessary. 

That  all  of  these  conditions  are  of  the  greatest  importance  may  be  demon- 
strated practically,  with  the  greatest  ease,  by  comparing  the  relative  frequency 
of  hernia  in  children  of  the  very  ignorant  poor,  of  the  intelligent  poor,  and  of 
the  well-to-do.  In  the  former  class,  after  the  child  is  weaned,  but  little 
attention  is  given  to  its  diet,  to  the  state  of  its  bowels,  and  to  the  condition  of 
the  prepuce  in  boj^s,  and  consequently  hernias  are  very  common,  while  they 
are  much  less  common  in  the  second,  and  still  less  in  the  third  class. 

STRANGULATED  HERNIA  IN  CHILDREN      • 

If  a  strangulated  hernia  in  a  child  cannot  be  easily  reduced,  under  com- 
plete anesthesia,  by  taxis,  the  child  being  held  in  the  inverted  position  during 
the  manipulations,  it  is  undoubtedly  wiser  to  relieve  the  danger  by  an  opera- 
tion, because  the  intestinal  wall  in  children  is  very  delicate  and  easily  injured 
by  taxis.  In  our  experience  the  hernial  opening  has  always  been  very  narrow ; 
still  we  have  always  succeeded  in  replacing  the  hernial  contents,  without 
enlarging  the  opening,  by  first  drawing  out  more  intestine  and  then  gradually 
replacing  it,  the  child  being  maintained  in  the  inverted  position. 

Technique.  If  the  hernia  is  an  acquired  one,  which  is  not  common  in 
children,  the  sac  is  carefully  dissected  free  to  a  point  within  the  abdominal 
cavity.  It  is  then  ligated  and  removed  and  the  ligated  stump  permitted  to 
retract  into  the  peritoneal  cavity. 

If  the  hernia  is  congenital  it  is  best  to  dissect  up  the  neck  of  the  sac  for 
about  an  inch,  and  leave  the  portion  surrounding  the  testicle  to  form  a  tunica 
vaginalis,  while  the  upper  portion  is  carefully  dissected  up  to  a  point  within 
the  peritoneal  cavity;  it  is  then  ligated,  the  superfluous  portion  is  cut  away 
and  the  stump  permitted  to  retract  into  the  peritoneal  cavity,  as  in  case  of 
the  acquired  hernia.  It  is  thus  only  necessary  to  close  the  skin  and  the  opening 
will  close  completely  in  from  four  to  six  weeks  if  the  child  is  kept  in  bed 
with  the  foot  of  the  bed  elevated. 


GENERAL  SURGERY  OF  THE  ABDOMEN  367 

If  it  is  possible  to  reduce  a  strangulated  hernia  in  children  by  taxis,  the 
irritation,  caused  primarily  by  the  strangulation  and  secondarily  by  the  manip- 
ulation, seems  to  favor  closure  of  the  hernial  opening.  We  have  repeatedly 
seen  this  occur  within  six  weeks  if  the  child  was  kept  in  bed  in  the  partly 
inverted  position. 

Unfavorable  cases.  The  most  unfavorable  cases  are  those  in  which  the 
abdominal  walls  are  congenitally  weak,  a  condition  which  seems  to  be  heredi- 
tary in  many  patients.  Again,  of  these  cases  those  in  which  there  are  three 
distinct  areas  of  weakness — the  abdomen  of  three  hills  described  by  Malgaigne 
— seem  to  be  least  favorable  of  all.  In  this  class  surgical  treatment  may  become 
necessary,  and  here  it  is  well  to  perform  the  typical  Bassini  operation,  or  that 
described  by  Ferguson,  the  important  point  in  the  operation  being  to  secure 
an  accurate  closure  of  the  inguinal  canal  to  make  up  for  the  natural  deficiency 
in  the  tissues.  Two  precautions  should  be  borne  in  mind :  1,  The  stitches 
should  be  tied  very  loosely,  in  order  not  to  cause  pressure-necrosis  of  the 
already  weakened  tissues.  2,  The  tissues  of  the  cord  in  the  male  should  be 
manipulated  very  carefully  for  fear  of  causing  an  atrophy  of,  or  preventing 
the  full  development  ol  the  testicle.  This  is  esoecially  important  in  these  cases 
because  hernige  in  this  class  of  patients  are  very  likely  to  be  double,  and  if  both 
testicles  should  atrophy  the  patient  would  be  permanently  injured.  In  this 
class  frequently  no  truss  will  retain  the  hernia. 

There  is  but  one  other  condition  which  justifies  the  operative  treatment  of 
hernia,  in  children,  and  that  is  when,  on  account  of  adhesions,  the  hernia, 
although  not  strangulated,  is  still  irreducible.  In  this  class  a  truss  cannot  be 
worn  with  benefit  because  it  presses  on  the  hernial  contents,  usually  omentum, 
instead  of  the  empty  canal ;  moreover,  the  opening  not  being  empty,  its  closure 
is  necessarily  impossible  unless  the  adhesions  are  absorbed,  which,  if  occurring 
at  all,  necessarily  requires  a  long  period  of  time.  In  this  variety  of  hernia, 
unless  it  be  complicated  with  the  form  just  described,  it  is  not  necessary  to  do 
anything  further  than  in  case  of  strangulated  hernia.  The  hernial  sac  being 
removed,  the  opening  will  close  spontaneously. 

In  operation  for  relief  of  femoral  hernia  in  children  it  is  never  necessary 
to  do  anything  beyond  dissecting  out,  ligating  and  cutting  away  the  sac,  per- 
mitting the  stump  to  retract  into  the  peritoneal  cavity,  and  closing  the  skin. 
These  cases  are  exceedingly  rare.  "We  have  never  seen  a  strangulated  femoral 
hernia  in  a  child,  and  only  once  an  irreducible  one  due  to  an  adherent  omen- 
tum, which  necessitated  an  operation. 

Use  of  trusses.  Too  much  stress  has  been  laid  upon  the  importance  of 
trusses  in  the  treatment,  and  too  little  on  removing  the  causes,  of  hernia  in 
children. 

It  is  far  easier  to  retain  a  hernia  and  thus  encourage  the  closure  of  the 
hernial  opening,  by  first  relieving  the  abnormal  intra-abdominal  pressure  and 
then  applying  the  truss  simply  as  an  aid,  than  it  would  be  to  accomplish  the 
same  object  by  the  use  of  the  truss  alone. 

If  it  is  at  all  possible  it  is  always  best  to  place  the  child  in  bed  in  the  in- 
verted position,  and  to  reduce  the  intra-abdominal  pressure  by  the  methods 
which  have  been  described,  before  making  use  of  a  truss  at  all.  Then,  if  it  is 
not  possible  to  maintain  this  position  sufficiently  long  to  obtain  a  cure  it  is 
well  to  apply  a  perfectly-fitting  truss. 

The  fact  of  using  a  truss  does  not  make  the  other  precautions  unnecessary. 
The  child  should  still  be  cared  for  so  as  to  remove  intra-abdominal  pressure 
from  every  cause,  and  the  foot  of  its  bed  should  still  be  elevated  in  order  to 
make  use  of  gravity  in  keeping  the  hernia  empty  and  to  facilitate  the  shorten- 
ing of  the  mesentery. 

Pertinent  conclusions.  The  following  conclusions  seem  to  cover  the  treat- 
ment of  hernia  in  children. 


368  GENERAL  SURGERY  OP  THE  ABDOMEN 

1.  The  development  of  hernia  in  children  is  favored  by:  (a)  faulty  de- 
velopment of  the  abdominal  wall;  (b)  insufficient  strength  in  the  tissues  in- 
volved in  closing  the  umbilical,  inguinal  or  femoral  openings;  (c)  abnormal 
intra-abdominal  pressure;  (d)  unclosed  condition  of  the  tunica  vaginalis. 

2.  The  causes  (a)  and  (b)  are  likely  to  be  inherited. 

3.  The  abnormal  intra-abdominal  pressure  is  due:  (a)  to  gaseous  dis- 
tension resulting  from  improper  feeding;  (b)  to  the  exertion  necessary  to 
accomplish  defecation  in  case  of  chronic  constipation;  (c)  to  the  same  exertion 
necessary  to  evacuate  the  bladder  on  account  of  obstruction  due  to  phimosis; 
(d)    to  severe,   long-continued   coughs. 

4.  A  large  majority  of  ail  cases  of  hernia  in  children  will  heal  spon- 
taneously if  the  increased  intra-abdominal  pressure  is  relieved,  the  hernial 
sac  being  kept  empty. 

5.  This  may  be  accomplished  by  means  of  a  truss  or,  much  more  rapidly, 
in  inguinal  and  femoral  hernia,  by  placing  the  child  in  bed  with  the  foot  of 
the  bed  elevated,  the  time  required  usually  not  exceeding  six  weeks. 

6.  Children  with  a  tendency  to  the  formation  of  hernia  should  be  guarded 
against  developing  coughs. 

7.  Their  diet  should  be  given  at  regular  times  and  chosen  with  a  view  to 
avoiding  gaseous  distension. 

8.  Constipation  should  be  entirely  prevented. 

9.  In  case  of  boys,  phimosis  should  be  relieved,  if  present. 

10.  Badly-nourished  and  badly-cared-for  children  of  the  poor  should  be 
treated  in  hospitals,  being  placed  in  bed  in  the  inverted  position,  the  cause  of 
increased  intra-abdominal  pressure  being  removed  at  the  time  by  proper 
treatment. 

11.  Operation  is  indicated  (a)  in  strangulated  hernia;  (b)  in  irreducible 
hernia  due  to  adhesions;  (c)  in  case  the  opening  is  unusually  large  in  a  free 
hernia,  especially  if  the  condition  is  hereditary  and  the  hernia  cannot  be 
retained  by  means  of  a  truss;  (d)  in  reducible  hydrocele, 

12.  Except  in  class  c,  the  operation  should  consist  simply  in  carefully 
dissecting  out  the  sac,  ligating  it  within  the  abdominal  cavity,  cutting  away 
the  sac  and  permitting  the  stump  to  retract  within  the  abdominal  cavity,  and 
simply  closing  the  wound  in  the  skin. 

13.  The  recumbent  position,  with  the  foot  of  the  bed  elevated,  is  of  very 
great  importance  in  the  operative  as  well  as  in  the  non-operative  treatment 
of  hernifE  in  children. 

14.  If  the  child  cannot  be  kept  in  this  position  sufficiently  long,  a  well- 
fitting  truss  should  be  worn  night  and  day  until  there  has  been  no  protrusion 
for  at  least  six  months,  at  the  same  time  the  necessary  precautions  being  con- 
stantly taken  to  guard  against  intra-abdominal  pressure  from  any  cause. 

HERNIA  IN  OLD  MEN 

It  frequently  happens  that  a  male  patient  can  easily  retain  his  hernia  by 
means  of  a  truss  until  he  has  attained  the  age  of  about  sixty  years,  when  he  is 
no  longer  able  to  do  this,  and  consequently  seeks  relief  through  a  surgical 
operation. 

He  may  have  grown  obese  or  his  tissues  may  have  become  soft  and  less 
able  to  resist  intra-abdominal  pressure,  but  there  is  an  important  factor  in 
the  increased  intra-abdominal  pressure  required  in  emptying  the  bladder  on 
account  of  an  obstruction  to  the  passage  of  the  urine,  caused  by  an  enlarged 
prostate  gland.     This  is  very  common  in  old  men. 

In  quite  a  large  proportion  there  will  be  a  rapid  reduction  in  the  size  of 
the  prostate  gland  if  either  a  vasectomy  or  an  orchidectomy  is  done.     Both 


GENERAL  SURGERY  OF  THE  ABDOMEN 


369 


of  these  operations  can  be  made  very  easily  in  connection  with  herniotomy 
without  increasing  the  danger  to  the  patient,  and  as  both  remove  some  of 
the  loose  tissue  in  the  inguinal  canal  they  favor  permanency  of  cure  in  two 
ways :  1,  by  making  the  union  between  the  layers  to  be  united  more  perfect, 
and  2,  by  decreasing,  indirectly,  the  excessive  intra-abdominal  pressure  by 
reducing  the  size  of  the  prostate  gland. 

In   many   of   these   cases  it   is   undoubtedly  best   to   perform   a   perineal 
prostatectomy  as  well  as  a  herniotomy.     If  the  patient's  general  condition  is 


Indirect  Oblique  Inguinal  Hernia  Descending  into  the  Scrotum.  Hernia  Always 
Reducible.  External  Inguinal  Ring  2  cm.  in  Diameter.  Treatment — Herniotomy 
(Ferguson- Andrews  Method). 

good  both  of  these  operations  may  be  accomplished  at  the  same  time,  if  not, 
it  is  probably  best  to  make  a  herniotomy  together  with  an  orchidectomy  first, 
and  if  this  fails  to  produce  a  sufficient  atrophy  of  the  prostate  gland  to  do  a 
prostatectomy  later. 

If  the  prostatic  trouble  is  very  pronounced  so  that  the  patient  has  to  get 
up  several  times  during  the  night  and  strain  to  urinate,  it  is  well  to  relieve 
the  prostatic  obstruction  before  operating  upon  the  hernia,  for  the  constant 
straining  is  likely  to  interfere  with  a  perfect  healing  of  the  tissues,  thus  bring- 
ing about  a  relapse  of  the  hernia. 

The  greatest  proportion  of  strangulation  occurs  in  patients  past  middle 
life.  It  is  not  uncommon  for  a  patient  to  have  a  hernia  for  forty  or  fifty 
years  that  has  always  been  easily  reducible,  and  then  become  suddenly  strangu- 
lated.   In  the  majority  of  cases  the  hernial  opening  increases  in  size  with  old 


370  GENERAL  SURGERY  OF  THE  ABDOMEN 

age,  and  the  protusion  constantly  slips  outside  of  the  truss,  increasing  the 
patient's  discomfort  and  placing  him  in  constant  danger  of  strangulation. 

In  operating  upon  old  people  one  frequently  finds  that  the  conjoined 
tendon  has  been  almost  completely  obliterated.  AVhen  this  condition  exists, 
it  is  well  to  transplant  the  cord  and  close  the  lower  angle  of  the  wound  as 
closely  as  possible.  When  the  obliteration  of  the  conjoined  tendon  is  very 
pronounced  this  lower  angle  can  be  closed  best  by  opening  the  sheath  of  the 
rectus  muscle  and  utilizing  that  muscle  in  the  closure,  after  the  method  of 
Bloodgood,  as  described  in  a  previous  section. 

STRANGULATED  HERNIA 

Type  of  case.  A  married  woman,  forty-six  years  of  age,  has  just  been  brought  to  the 
hospital.  From  her  daughter  we  learn  the  following  history:  The  patient  has  been  married 
for  twenty-six  years;  has  never  been  very  strong,  but  always  comparatively  well.  She  is  the 
mother  of"  four'  healthy  children.  For  many  years  she  has  felt  a  weakness  in  the  region  of 
the  left  groin  and  since  twelve  years  old  has  known  of  the  presence  of  a  femoral  hernia, 
which,  however,  has  given  rise  to  but  little  distress  except  when  she  has  worked  beyond  her 
strength.  Occasionally  the  hernia  has  been  painful  and  the  patient  has  experienced  difficulty 
in  reducing  it,  but  this  has  never  been  serious  in  character  and  she  has  always  succeeded  in 
obtaining  relief  by  lying  down  and  applying  hot  cloths  to  the  part  for  an  hour  or  two. 

Three  days  ago  the  patient  suddenly  became  severely  nauseated  and  had  great  pain  in  the 
abdomen.  She  attributed  this  to  something  eaten  and  imagined  that  it  would  soon  improve. 
She  consequently  made  use  of  home  remedies  and  did  not  send  for  her  physician  until  about 
sixteen  hours  ago.  When  he  arrived  he  found  the  patient  very  ill.  She  still  continued  to 
vomit,  there  had  been  complete  obstruction  to  the  passage  of  gas  and  feces,  the  abdomen 
was  moderately  distended  with  gas  and  the  abdominal  walls  were  tense.  In  the  region  of  the 
left  femoral  ring  there  was  a  hard  mass  the  size  of  a  hen's  egg.  The  pulse  was  a  little  over 
100  and  the  temperature  101°  F. 

The  physician  made  a  diagnosis  of  strangulated  femoral  hernia,  but  as  the  patient  did  not 
suffer  from  severe  pain  in  the  vicinity  of  the  hernia  he  did  not  lay  very  great  weight  upon  this 
part  of  the  diagnosis.  He  elevated  the  foot  of  the  bed  in  order  to  make  use  of  gravitation  for 
the  purpose  of  reducing  the  hernia,  gave  a  hypodermic  injection  of  morphia  to  relax  the 
muscles,  directed  the  patient  to  remain  in  the  position  assumed  and  continue  the  application 
of  hot  fomentations.     He  also  forbade  the  giving  of  any  kind  of  food  by  mouth. 

The  physician  then  left  the  patient  and  returned  after  six  hours,  only  to  find  her  very 
much  worse  in  every  respect.  He  then  advised  an  immediate  operation,  but  the  husband  could 
not  be  found  for  seven  hours  more,  and  by  the  time  the  latter  was  convinced  of  the  necessity 
of  an  operation  the  patient  was  in  the  present  extreme  condition.  Her  face  is  pale,  lips  blue, 
respiration  very  shallow,  pulse  imperceptible,  and  she  is  without  doubt  in  a  dying  condition. 
The  pupils  are  becoming  more  and  more  dilated,  indicating  that  death  will  occur  within  a  few 
moments. 

Such  a  case  is  unusually  instructive  because  the  conditions  present  are  so 
frequently  encountered  in  practice. 

Prognosis.  In  the  discussion  of  hernia  operated  for  the  radical  cure,  when 
not  strangulated,  the  fact  was  pointed  out  that  the  operation  is  almost  abso- 
lutely safe,  the  death  of  a  case  depending  upon  an  accident.  The  same  is  true 
in  operation  for  the  relief  of  strangulated  hernia  at  the  beginning  of  the  attack, 
because  the  only  additional  element,  the  strangulation,  m.&y  be  relieved  with- 
out difficulty  and  without  danger  to  the  patient  so  long  as  there  has  been  no 
injury  to  the  strangulated  intestine.  Consequently  every  death  following  a 
strangulated  hernia— barring  the  accidents  which  may  occur  in  connection 
with  any  operation—is  due  to  the  fact  that  a  physician  has  not  been  called  at 
the  beginning  of  the  attack,  or  his  advice  to  obtain  immediate  relief  has  not 
been  accepted,  or  the  physician  himself  has  wasted  valuable  time. 

Prompt  operative  measures  necessary.  There  can  be  no  doubt  but  that  all 
temporizing  in  the  treatment  of  strangulated  hernia  should  be  strongly  con- 
demned, because  cases  in  which  relief  is  obtained  in  this  manner  could  all  be 
relieved  by  manipulation  of  the  hernia  under  an  anesthetic,  and  those  that  are 
not  relieved  would  recover  were  they  operated  early.    Every  year  thousands 


GENERAL  SURGERY  OF  THE  ABDOMEN  371 

of  patients  lose  their  lives  unnecessarily  from  strangulated  hernia  because  time 
is  wasted  either  on  account  of  their  own  ignorance  or  stubbornness,  or  because 
of  carelessness  in  examination  by  the  physician  called  or  his  lack  of  decision 
in  obtaining  relief  at  once.  Moreover,  it  should  be  remembered  that  any  prac- 
titioner who  has  sufficient  intelligence  and  training  to  have  clean  hands  and 
instruments,  and  a  fair  knowledge  of  what  to  do,  will  save  a  larger  proportion 
of  cases  suffering  from  strangulated  hernia  by  operating  at  the  beginning  of 
the  attack  than  will  a  surgeon  of  the  very  greatest  skill  and  training  after  the 
tissues  involved  have  become  gangrenous. 

A  lay  misunderstanding.  At  this  point  we  wish  to  make  a  suggestion 
which  seems  to  be  of  great  practical  importance  so  long  as  patients  and  their 
friends  are  justly  afraid  of  surgical  operations  for  the  relief  of  strangulated 
hernia  because  many  of  their  friends  who  have  submitted  to  this  operation 
have  not  recovered.  It  is  difficult  for  the  layman  to  understand  that  his  friend 
died,  after  an  operation  for  the  relief  of  strangulated  hernia,  because  the  opera- 
tion was  performed  when  he  was  already  in  a  hopeless  condition ;  for  this  fact 
should  have  prevented  the  operation  which  was  at  least  useless,  as  was  shown 
by  the  result.  It  is  difficult  for  him  to  understand  why  his  own  chance  of 
recovery  should  be  better  than  his  friend's,  inasmuch  as  his  friend  was  urged 
to  submit  to  an  operation  with  the  same  arguments  that  are  being  employed  in 
his  case.  In  other  words,  the  large  number  of  deaths  following  operations  for 
strangulated  hernia,  where  the  operation  had  been  postponed  until  the  patient 
was  in  a  hopeless  state,  prevents  the  operation  in  the  case  under  immediate 
consideration  until  it,  likewise,  is  too  late  to  be  of  value. 

This  prejudice  can  usually  be  overcome  in  the  following  manner:  Describe 
to  the  patient  the  condition  which  is  present ;  tell  him  that  a  loop  of  intestine 
is  caught  in  a  ring  and  constricted  as  tightly  as  his  finger  would  be  were  a 
string  tied  about  it  sufficiently  firm  to  prevent  all  circulation  of  blood.  lie 
will  understand  that  this  must  soon  be  folloAved  by  death  of  the  tissues  and 
that  then  the  contents  of  the  intestines  will  leak  into  the  abdominal  cavity  and 
that  will  be  followed  very  speedily  by  his  death.  Tell  him  that  you  will  make 
every  effort  to  reduce  the  strangulation  by  manipulating  the  tissues,  in  order 
to  induce  the  intestine  to  slip  back  through  the  ring. 

Taxis.  Place  the  patient  on  a  couch  or  a  board,  or  if  this  cannot  be 
obtained  take  a  door  out  of  its  frame  and  lay  the  patient  on  it ;  then  elevate 
the  lower  end  of  this  so  that  it  will  be  at  an  angle  of  about  40°  with  the  floor. 
Have  him  draw  up  his  knees  and  then  manipulate  the  protruding  portion 
gently,  so  as  not  to  cause  any  injury  to  the  intestine,  remembering  that  the 
longer  the  strangulation  has  existed,  the  more  gentle  must  be  the  manip- 
ulations. 

It  is  well  to  permit  the  patient  to  manipulate  the  hernia  himself  while  he 
is  in  this  position,  because  he  is  frequentlj^  more  experienced,  and  consequently 
may  be  more  successful  than  the  physician.  If  reduction  is  accomplished,  it  is 
well,  if  not,  it  is  best  to  explain  to  the  patient  that  by  relaxing  the  muscles,  by 
the  use  of  an  anesthetic,  you  may  still  be  successful,  but  if  this  fails,  it  will 
become  necessary  to  sever  the  circular  band  which  prevents  the  reduction  of 
the  hernia. 

This  will  seem  so  reasonable  to  the  patient  that,  in  our  experience,  with 
only  one  exception,  the  patient  has  always  consented  when  the  conditions  have 
been  placed  before  him  in  this  manner.  One  substitutes  the  object,  namely, 
the  reduction  of  the  hernia,  for  the  operation  in  the  mind  of  the  patient.  This 
is  really  important. 

Operative  preparation.  It  is  best  to  permit  the  patient  to  continue  in  the 
inverted  position  while  the  necessary  preparations  are  being  made,  which 
should  be  very  simple,  as  described  in  the  section  on  preparation  for  operation. 


372  GENERAL  SURGERY  OF  THE  ABDOMEN 

If  a  colleague  is  available  lie  should  be  called  iu  the  meantime,  if  not,  this 
should  not  interfere  with  the  plan  of  action,  because  time  is  the  element  of 
greatest  importance  in  these  cases. 

If  the  patient  is  iu  a  hospital  it  h  "wise  always  to  anesthetize  the  pharynx 
by  spraying  it  with  a  four  per  cent,  solution  of  cocaine  in  water,  then  insert  a 
stomach  tube  and  carefulh*  wash  out  the  stomach,  because  these  patients  fre- 
quently vomit  during  the  operation  and  inspire  the  offensive  material  which 
has  decomposed  in  the  stomach,  a  pneumonia  perhaps  resulting.  In  a  private 
house,  especially  in  the  country,  these  preparations  may  not  be  possible, 
although  it  is  well  always  to  carry  a  stomach  tube.  In  this  case  the  patient 
may  be  protected  by  being  kept  in  an  exaggerated  Trendelenburg  position 
throughout  the  anesthesia,  because  in  this  way  the  vomited  material  Avill  escape 
from  the  mouth  by  gravitation  before  it  can  be  inspired. 

AYhen  the  patient  has  been  thoroughly  anesthetized  another  attempt  may 
be  made  to  reduce  the  hernia  bj'  manipulation,  and  if  this  fails,  herniotomy 
should  be  performed  at  once.  During  these  manipulations  it  is  again  neces- 
sary to  bear  in  mind  that  if  the  strangulation  has  lasted  only  a  few  hours  a 
considerable  amount  of  force  may  be  exerted  with  safety,  while  it  is  not  wise 
to  use  any  force  if  the  strangulation  has  existed  for  more  than  twent^^-four 
hours  for  fear  of  rupturing  the  intestine. 

Symptom  resume.  Before  describing  the  operation  we  wish  to  direct  atten- 
tion once  more  to  the  above  history,  which  is  quite  characteristic  in  many 
respects.  1.  The  onset  was  sudden.  2.  There  were  severe  spasmodic  pains  in 
the  abdomen.  3.  The  patient  suffered  from  nausea  and  vomiting  and  conse- 
quently attributed  her  trouble  to  an  error  in  eating.  4.  There  has  been  com- 
plete obstruction  to  the  passage  of  gas  and  feces.  5.  There  was  a  history  of 
the  presence  of  a  hernia.  6.  A  mass  existed  in  the  groin.  7.  The  patient  felt 
severely  ill  from  the  beginning.  8.  She  went  into  a  hopeless  condition  of 
collapse  very  suddenly. 

The  physical  examination,  when  first  seen  by  the  physician  at  the  begin- 
ning of  her  collapse,  showed  a  patient  with  a  bad  facial  expression,  the  tongue 
was  thickly  coated,  temperature  and  pulse  not  very  high,  but  the  pulse  bad  in 
character,  the  patient  was  restless,  the  abdominal  walls  were  tense,  the  abdo- 
men somewhat  distended  M'ith  gas.  The  peristalsis  of  the  small  intestines  could 
be  distinguished  through  the  abdominal  wall  to  some  extent.  There  was 
complete  obstruction  to  the  passage  of  gas  and  feces.  In  the  inguinal  region 
there  was  a  very  tense  swelling  which  could  not  be  reduced. 

Differential  diagnosis.  The  history  of  a  reducible  hernia  which  had  existed 
for  a  considerable  period  of  time,  and  the  presence  of  an  immovable  mass  in 
the  inguinal  region  at  the  point  at  which  the  reducible  hernia  could  be  located 
by  the  patient,  would  in  itself  warrant  a  positive  diagnosis  of  strangulated 
hernia  in  the  presence  of  complete  intestinal  obstruction. 

"Without  the  previous  history  of  a  reducible  hernia  the  mass  in  the  groin 
might  be  due  to  a  severe  inflammation  of  the  inguinal  lymph  glands.  We  have 
seen  a  case  of  acute  intestinal  obstruction  due  to  perforative  appendicitis, 
complicated  with  bubo,  in  which  the  latter  might  have  been  diagnosed  as  a 
strangulated  hernia  had  not  the  attending  physician  treated  the  patient  pre- 
viously for  a  specific  urethritis.  The  most  common  mistake  in  diagnosis  is 
that  of  acute  gastritis,  because  the  physician  is  willing  to  make  a  diagnosis 
from  the  history  alone  without  making  a  physical  examination  of  the  abdomen, 
the  patient  either  neglecting  to  mention  the  fact  of  having  a  hernia  or  this  fact 
being  passed  over  without  notice.  An  acutely  inflamed  tumor  in  this  region 
may  be  mistaken  for  a  strangulated  hernia. 

In  quite  a  number  of  these  cases  which  have  come  under  our  observation 
the  patient  insisted  that  the  hernia  had  been  irreducible  for  many  years  and 


GENERAL  SURGERY  OF  THE  ABDOMEN  373 

that  it  could  consequently  not  be  the  cause  of  the  severe  gastric  disturbances. 
Moreover,  the  attack  came  on  directly  after  some  indiscretion  in  eating  and 
must  consequently  depend  upon  this  and  not  upon  the  hernia,  which  had 
remained  unchanged.  The  unusual  hardness  of  the  hernia  is  supposed  to 
correspond  to  the  tension  in  the  abdominal  walls,  due  to  the  intra-abdominal 
irritation.  In  this  manner  a  strangulated  hernia  is  mistaken  for  a  simple 
irreducible  hernia  which  is  caused  by  the  adhesion  of  a  portion  of  the  omentum 
within  the  hernial  sac. 

In  these  cases  the  operation  usually  shows  that  a  loop  of  intestine  has 
slipped  into  the  hernial  sac  alongside  of  the  omentum  and  has  become  strang- 
ulated by  the  sharp  ring  formed  by  the  connective  tissue  in  the  neck  of  the 
hernial  sac. 

A  strangulated  right  inguinal,  or  femoral  hernia,  may  be  mistaken  for  an 
acute  appendicitis.  In  several  instances  we  have  encountered  a  gangrenous 
appendix  in  a  strangulated  hernia,  and  many  such  cases  have  been  reported. 

We  have  encountered  a  preperitoneal  inguinal  hernia,  strangulated  for  one 
week,  containing  20  cm.  of  small  intestine  which  was  strangulated  by  the 
thickened  peritoneal  circular  constricting  band  of  the  internal  abdominal  ring. 
The  intestine  after  passing  through  this  ring  had  passed  between  the  trans- 
versalis  fascia  and  the  peritoneum  instead  of  entering  the  inguinal  canal.  Here 
it  became  gangrenous  and  perforated  without  being  discovered  until  the 
patient  was  brought  into  the  hospital  sufit'ering  from  hopelessly  advanced 
peritonitis. 

A  strangulated  hernia  so  small  as  to  be  overlooked  has  been  mistaken 
for  every  variety  of  mechanical  obstruction  of  the  bowels,  but  if  a  careful 
physical  examination  is  made  this  is  not  likely  to  occur. 

In  almost  every  case  in  which  an  error  in  diagnosis  is  made  in  strangulated 
hernia  this  is  due  to  the  fact  that  the  physical  examination  has  not  been 
sufficiently  careful. 

Etiology.  The  strangulation  is  usually  due  to  the  fact  that  a  small  loop  of 
intestine  has  been  forced  out  into  the  hernial  sac,  which  existed  previously,  by 
some  unusual  exertion,  and  that  the  connective  tissue  forming  the  neck  of  the 
sac  has  constricted  the  intestine  at  the  point  at  which  it  issued  from  the  abdom- 
inal cavity,  and,  interfering  with  the  return  circulation  the  portion  of  the 
intestine  contained  in  the  sac  becomes  congested  and  edematous.  The  drainage 
from  the  lumen  of  the  intestine  is  obstructed  at  the  same  time,  which  favors 
the  multiplication  of  micro-organisms  contained  in  the  intestinal  contents. 
With  the  increasing  edema  the  circulation  is  presently  shut  off  entirely  and 
the  loop  of  intestine  becomes  gangrenous  and  perishes,  becoming  an  excellent 
nourishing  medium  for  the  micro-organisms  in  its  lumen. 

In  the  meantime  the  complete  intestinal  obstruction  has  injured  the  portion 
of  intestine  above  the  constricting  ring,  because  there  is  c.  certain  amount  of 
tension  upon  the  mesenteric  vessels  interfering  with  the  nutrition.  The  pres- 
sure within  the  lumen  of  the  intestines  is  greatly  increased  by  the  accumula- 
tion of  gas  within  the  bowel,  due  to  the  decomposition  of  the  contents  which 
cannot  be  expelled.  Too  often  this  pressure  is  increased  to  a  marked  extent 
by  the  administration  of  food  and  cathartics  by  mouth.  Presently  the 
distension  of  these  intestines  will  be  sufficient  to  permit  transmission  of 
micro-organisms  contained  in  their  lumen  resulting  in  a  direct  infection  of  the 
Deritoneal  cavity.  In  the  meantime  again  the  infection  from  the  gangrenous 
intestine  within  the  hernial  sac  may  result  in  a  thrombosis  of  the  mesenteric 
vessels  in  the  intestine  in  the  peritoneal  cavity,  causing  an  extension  of  the 
gangrene. 

Treatment.  From  the  moment  a  patient  with  strangulated  hernia  comes 
under  care  we  must  absolutely  prohibit  the  giving  of  food  and  cathartics  by 


374  GENERAL  SURGERY  OF  THE  ABDOMEN 

mouth,  because  this  can  only  serve  to  increase  the  pressure  within  the  intestine 
and  may  also  serve  to  force  infectious  material  through  the  intestinal  wall. 

If  the  patient  comes  under  care  within  the  first  twenty-four  hours  it  is 
usually  safe  to  make  quite  a  prolonged  effort  to  reduce  the  hernia  by  means 
of  manipulations,  the  patient  lying  upon  his  back  with  the  lower  end  of  the 
table  or  couch  elevated  to  an  angle  of  about  40°,  with  the  knees  drawn  up  in 
case  of  femoral  or  inguinal  hernia,  or  with  the  patient  lying  flat  on  his  back 
in  case  of  umbilical  or  ventral  hernia.  But  even  in  these  cases  which  come 
under  care  early,  we  must  be  careful  not  to  injure  the  intestine  by  using  too 
much  force.  If  the  strangulation  has  existed  much  longer,  still  greater  cau- 
tion, as  before  mentioned,  must  be  exercised.  This  is  especially  true  of  very 
small  herniae  in  which  the  intestine  is  often  hopelessly  destroyed  even  after 
thirty-six  hours,  in  which  case  its  return  to  the  abdominal  cavity  would  almost 
inevitably  result  in  a  diffuse  peritonitis  and  death  of  the  patient. 

Failing  in  the  reduction,  an  immediate  operation  is  of  course  indicated,  and 
this  can  usually  be  done  directly  after  the  attempt  at  reduction  under 
anesthesia  has  been  made,  without  permitting  the  patient  again  to  gain 
consciousness. 

If  possible,  it  is  always  best  in  these  patients  to  perform  gastric  lavage  as 
described  above.  Aside  from  this  nothing  need  be  done  beyond  carefully 
scrubbing,  shaving  and  disinfecting  the  field  of  operation  and  covering  the 
remaining  portions  of  the  body  with  sterilized  towels. 

Operative  technique.  We  will  here  speak  of  the  three  common  forms  of 
strangulated  hernia,  femoral,  ingviinal  and  umbilical,  together,  because  the 
same  principles  apply  to  all  alike. 

An  incision  is  made  over  the  center  of  the  swelling,  the  successive  layers  of 
tissue  being  elevated  between  two  pairs  of  dissecting  forceps  in  order  to  facil- 
itate the  work  by  protecting  the  underlying  tissues.  If  the  hernia  has  existed 
a  considerable  period  of  time  the  discolored  intestine  will  shine  through  the 
hernial  sac,  which  may  be  smooth  and  shining,  or  it  may  be  roughened  and 
adherent  to  the  overlying  tissues.  This  condition  is  especially  likely  to  be 
present  if  the  hernia  has  existed  for  a  long  time,  and  if  a  tightly-fitting  truss 
has  been  worn. 

Precautions.  If  the  layers  are  picked  up  with  two  pairs  of  forceps  and 
the  incision  made  only  through  tissue  thus  elevated  there  is  no  danger  of 
wounding  the  intestine  within  the  hernial  sac.  Occasionally  one  encounters  a 
thick  layer  of  pre-peritoneal  fat  on  the  outer  surface  of  the  sac  which  looks 
so  much  like  omentum  that  it  is  quite  confusing.  It  is  well  to  watch  for  the 
hernial  fluid  which  can  always  be  found  in  the  sac  in  strangulated  hernia. 
Frequently  there  is  a  sufficient  quantity  to  protect  the  contents  of  the  sac 
from  injury  in  making  the  incision,  but  quite  as  often  the  quantity  is  very 
slight ;  still  we  believe  it  is  always  sufficient  to  indicate  the  fact  that  the  sac 
has  been  opened. 

There  is,  however,  one  source  of  error  which  has  been  observed  in  prac- 
tice. Occasionally  the  bladder  is  drawn  into  the  hernial  sac  and  this  has  been 
opened  and  the  urine  which  escaped  has  been  mistaken  for  hernial  fluid.  In 
case  of  doubt  in  this  direction  it  is  well  to  introduce  a  steel  sound  into  the 
bladder  and  examine  this  organ  in  the  direction  of  the  hernia.  In  case  the 
accident  has  happened  it  is  best  to  suture  the  wound  in  the  bladder  at  once 
with  a  double  row  of  Lembert  sutures  of  catgut.  It  is  necessary  to  observe 
three  precautions  in  suturing  such  a  wound  in  the  bladder :  1.  The  stitches 
must  be  applied  with  great  regularity  in  order  to  make  the  closure  imper- 
meable to  water.  2.  The  stitches  should  not  protrude  into  the  cavity  of  the 
bladder,  in  order  to  prevent  formation  of  stone.  3.  They  should  be  tied 
sufficiently  loose  to  prevent  pressure  necrosis  at  any  point. 


GENERAL  SURGERY  OF  THE  ABDOMEN  375 

After  the  hernial  sac  has  been  opened  and  the  hernial  fluid  carefully 
sponged  away,  the  intestine  should  be  inspected.  If  this  is  covered  by  an 
uninjured,  smooth,  shining  peritoneum  it  is  likely  that  it  will  revive  even 
though  it  may  be  quite  black.  It  is  not  wise  to  attempt  its  reduction  without 
enlarging  the  constricting  ring  at  the  neck  of  the  hernial  sac  because  the 
strangulated  loop  of  intestine  has  already  suffered  so  severely  that  it  is 
injudicious  to  injure  it  further  by  unnecessary  manipulations. 

Cutting"  the  constricting'  ring.  Many  methods  of  cutting  the  constricting 
ring  have  been  advised,  but  unless  the  operator  has  through  experience 
acquired  especial  skill  in  the  use  of  one  of  these  methods  we  would  advise  him 
to  make  the  incision  through  all  the  tissues  sufficiently  free  to  expose  the  edge 
of  the  constricting  ring  and  then  to  introduce  preferably  a  Kocher  director 
between  the  intestine  and  the  ring  and  then  a  scalpel  or  the  blade  of  scissors 
between  this  and  the  ring,  making  an  incision  transversely  across  the  con- 
stricting tissues.  The  strangulation  is  not  usually  caused  by  the  tissues  of  the 
abdominal  wall,  but  by  a  hard,  inelastic,  fibrous  ring  developed  from  the 
tissues  composing  the  neck  of  the  hernial  sac. 

In  femoral  hernia  it  is  well  to  cut  inward  in  order  to  cut  away  from  the 
femoral  vein.  In  inguinal  hernia  it  is  well  to  cut  in  the  direction  of  the 
inguinal  canal,  first  splitting  the  fibers  of  the  fascia  of  the  external  oblique 
abdominal  muscle,  as  described  in  the  operation  for  radical  cure  of  inguinal 
hernia.  If  it  becomes  necessary  to  cut  the  constricting  band  without  having 
it  exposed  to  sight,  it  is  well  to  insert  the  finger  into  the  canal  in  order  to 
determine  whether  the  epigastric  artery  is  in  the  normal  position.  If  it  is,  it 
can  be  easily  avoided ;  if  it  is  not,  it  will  be  best  to  enlarge  the  external  wound 
until  the  constricting  portion  is  in  view,  when  it  can  be  cut  safely  over  a 
director  or  over  the  finger  which  has  been  inserted  between  the  intestine  and 
the  constricting  ring.  It  is  now  possible  to  draw  out  a  further  portion  of  the 
intestine  for  inspection.  If  only  one  portion  has  been  hopelessly  destroyed 
by  the  pressure,  this  will  be  found  just  at  the  point  where  the  intestine  was 
grasped  by  the  constricting  ring.  Frequently  the  dark  color  of  the  entire  loop 
found  in  the  hernial  sac  will  begin  to  disappear  after  the  ring  has  been  cut 
and  the  circulation  in  that  portion  of  the  intestine  becomes  re-established. 

Determining  the  vitality  of  the  strangulated  gut.  Covering  this  portion 
with  pads  moistened  with  warm,  normal  salt  solution  for  a  minute  or  more 
the  intestine  appears  more  and  more  normal  and  when  irritated  by  touching 
it  the  muscles  respond  by  contracting.  In  such  case  it  is  safe  to  return  the 
intestine  into  the  abdominal  cavity  and  so  complete  the  operation  as  described 
under  radical  cure. 

Even  if  there  is  no  muscular  contraction,  but  a  satisfactory  return  of  the 
circulation,  it  is  safe  to  return  the  gut,  provided  the  peritoneal  covering  is 
smooth  and  shining.  If,  however,  there  are  areas  of  tissue  upon  the  peritoneal 
surface  which  are  roughened,  or  if  portions  show  by  their  thinness  that  some 
of  the  deeper  layers  of  the  intestinal  wall  are  actually  necrotic,  it  becomes 
necessary  to  remove  the  gangrenous  portion  and  to  unite  the  two  portions  of 
intestine  thus  severed. 

The  upper  branch  of  the  intestine  is  always  the  one  which  has  suffered  most 
because  the  peristaltic  pressure  has  forced  intestinal  contents  down  to  the 
point  of  obstruction,  consequently  this  portion  of  intestine  is  often  greatly 
distended  with  gas  and  feces.  Before  resecting  a  gangrenous  intestine  it  is 
best  to  make  an  abdominal  section  in  the  median  line  between  the  umbilicus 
and  pubis  and  after  cutting  away  the  gangrenous  portion  of  the  intestine  to 
bring  both  clamped  ends  of  the  intestine  out  through  the  abdominal  incision 
to  thoroughly  empty  the  contents  of  the  distended  loop  by  inserting  a  large 
glass  tube,  a  purse-string  suture  having  first  been  passed  around  the  intestine 


376  GENERAL  SURGERY  OF  THE  ABDOMEN 

one  or  two  cm.  from  the  free  end  to  prevent  leakage,  and  then  carefullj'" 
threading  the  intestine  upon  the  glass  tube  after  the  fashion  of  pulling  the 
finger  of  a  glove  upon  one's  finger.  By  thus  bringing  the  ends  of  the  intes- 
tines out  of  the  wound  it  is  possible  to  carefully  inspect  the  mesentery  in  order 
to  determine  the  condition  of  the  bloodvessels,  as  well  as  the  peritoneum 
covering  the  intestines. 

Resection  of  gangrenous  portion.  Before  cutting  away  the  gangrenous 
portion  of  intestine  it  is  necessary  to  provide  against  infection  of  the  peri- 
toneal cavity  from  its  contents  bj'  carefully  placing  warm,  moist  pads  of 
gauze  about  the  loop.  Two  pairs  of  long-jawed  compression  forceps  are 
applied  half  an  inch  apart,  and  two  or  three  inches  from  the  gangrenous  intes- 
tine, upon  the  lower  segment,  which  is  ordinarily  nearly  normal,  so  as  to  close 
the  lumen  of  the  intestine  completely,  the  points  of  the  forceps  reaching  about 
half  an  inch  beyond  the  mesenteric  attachment  of  the  intestine.  An  incision  is 
made  down  to  the  mesentery  betAveen  these  two  forceps,  then  the  mesentery 
of  the  gangrenous  portion  of  the  intestine  is  transfixed  and  ligated  with  catgut. 
It  is  best  to  do  this  in  several  sections  in  order  to  prevent  slipping  of  the 
stump. 

The  intestine  is  cut  loose  from  its  mesenteric  attachment  and  if  greatly 
distended  above  the  gangrenous  portion  it  is  well  to  have  the  patient  rolled 
over  to  the  side  of  the  operation,  and  after  carefully  applying  moist  gauze  pads 
about  the  wound  to  place  the  end  of  the  intestine  which  has  been  cut  loose 
from  its  mesentery  into  a  basin,  to  grasp  the  cut  edge  at  different  points  with 
hemostatic  forceps  and  then  to  remove  the  long-jawed  forceps  closing  the  end 
of  the  intestine.  In  this  manner  the  loosened  intestine  will  act  as  a  tube 
through  which  the  contents  of  the  upper  part  may  safelj^  be  emptied. 

In  order  to  obtain  a  safe  point  to  unite  the  lower  with  the  upper  segment 
of  the  intestine  it  is  necessary  to  sacrifice,  in  most  cases,  quite  a  long  piece  of 
the  upper  segment.  It  is  a  better  plan  to  close  both  cut  ends  of  the  intestine 
and  make  an  anastomosis  between  the  lower  segment  near  its  end  and  the 
upper  segment  far  enough  from  its  end  to  be  certain  that  the  intestinal  walls 
are  quite  normal.  In  this  way  quite  as  good  a  union  can  be  obtained  as  by 
resecting  a  large  portion  of  the  upper  segment,  and  much  time  is  saved  in  the 
operation,  as  well  as  much  shock,  because  the  amount  of  traumatism  is  very 
greatly  decreased  in  this  manner. 

The  portion  of  the  upper  segment  of  the  intestine  below  the  point  of  anas- 
tomosis remains  perfectly  harmless. 

The  methods  of  closing  the  ends  of  the  severed  intestine  and  making  the 
anastomosis  are  fully  described  in  the  section  on  intestinal  surgery. 

Removal  of  bowel  contents.  In  other  cases  in  which  it  is  not  necessary  to 
make  a  resection  of  the  bowel,  the  distended  intestine  should  be  emptied  after 
the  method  of  Marks.  This  consists  in  placing  a  purse-string  stitch  in  the  wall 
of  the  distended  intestine  making  a  circle  about  1  cm.  in  diameter,  the  ends 
of  the  stitch  remaining  loose.  An  opening  is  now  made  in  the  center  of  the 
purse-string  area  and  a  glass  tube  about  2  cm.  in  diameter  and  about  30  cm. 
long  is  inserted  into  the  intestine  and  the  purse-string  is  now  tied  to  prevent 
leakage  around  the  tube.  A  large  rubber  tube  is  slipped  onto  the  free  end 
of  the  tube  and  its  free  end  placed  in  a  basin.  The  intestine  is  now  gradually 
threaded  onto  this  glass  tube  and  as  this  is  done  the  intestinal  contents  are 
all  forced  out  through  the  glass  tube.  A  loop  of  intestine  at  about  the  center 
of  the  distended  intestines  should  be  chosen  as  a  point  to  insert  the  tube.  The 
glass  tube  is  first  directed  toward  the  upper  end  of  the  intestinal  canal  and  this 
half  emptied.  The  tube  is  then  withdrawn  until  it  can  be  directed  down  the 
lower  half  of  the  intestine  which  is  now  threaded  on  the  tube,  emptying  this 
portion  of  the  bowel.  The  tube  is  now  removed  and  the  opening  in  the  intes- 
tine closed  by  tj'ing  the  purse-string  stitch  and  placing  a  Lembert  stitch  over 


GENERAL  SURGERY  OF  THE  ABDOMEN  377 

it.    This  process  removes  a  large  amount  of  septic  material  from  the  alimentary 
canal  and  leaves  the  intestine  in  a  collapsed  condition. 

After-treatment.  After  operation  for  strangulated  hernia  no  food  should 
be  given  by  mouth  for  several  days,  and  then  only  predigested  substance  and 
later  broths,  soups  and  milk.  The  patient  may  be  nourished  by  enemata 
consisting  of  one  ounce  of  some  predigested  food  dissolved  in  three  ounces 
of  normal  salt  solution  given  every  four  hours.  Cathartics  should  not  be 
used  until  at  least  a  week  after  the  operation,  and  then  only  mild  salines  in 
small,  often  repeated  doses.  Small  sips  of  very  hot  water  may  usually  be  given 
from  the  first. 

The  treatment  of  the  wound  must  be  left  to  the  judgment  of  the  operator. 
If  it  seems  wise  to  close  the  wound  this  is  done  in  the  manner  described  in 
operations  for  radical  cure,  except  in  femoral  hernia.  In  femoral  hernia  the 
defect  made  in  the  ring  by  cutting  the  constriction  must  be  repaired  in  order 
to  prevent  the  recurrence  of  the  hernia.  This  can  be  accomplished  very  readily 
with  a  few  interrupted,  chromicized  catgut  stitches.  In  all  other  respects  the 
same  methods  may  be  followed  as  in  operation  for  radical  cure. 

If  in  any  given  case  it  seems  unwise  to  close  the  hernial  opening  at  once 
it  is  well  to  insert  a  glass  or  rubber  drainage  tube,  covered  with  iodoform 
gauze,  through  the  hernial  opening  down  to  the  injured  intestine.  It  has 
been  our  practice  to  withdraw  this  tube  on  the  second  or  third  day,  and  after 
that  to  withdraw  the  gauze  gradually,  by  pulling  upon  it  as  much  as  seems 
wise  each  day.  If  the  wound  suppurates,  it  is  to  be  treated  like  an  infected 
wound  elsewhere.  If  it  remains  aseptic  it  may  be  closed  by  means  of  secondary 
sutures  a  week  after  the  original  operation. 

This  operation  must  frequently  be  performed  in  old  and  feeble  patients, 
and  these  do  not  bear  confinement  in  bed  well.  It  is  consequently  wise  to 
encourage  their  moving  about  in  bed  and  sitting  up  early. 

If  a  fecal  fistula  occurs  it  is  well  to  continue  the  feeding  by  enema  for 
two  or  three  weeks,  which  will  usually  suffice  for  a  spontaneous  cure.  If  the 
fistula  persists  it  may  become  necessary  to  make  an  abdominal  section  for  its 
relief,  the  technique  of  which  will  be  found  under  intestinal  surgery. 

If  the  patient  seems  too  weak  to  bear  the  operation  of  anastomosis  of 
the  two  portions  of  the  intestine,  or  if  the  operator  who  performs  the  opera- 
tion does  not  feel  competent  to  conduct  this  part  of  the  work,  temporary 
relief  may  be  given  by  drawing  out  the  intestine  for  a  distance  of  two  or  three 
inches  through  the  enlarged  hernial  opening,  placing  strands  of  gauze  between 
the  intestines  and  the  edges  of  the  opening,  ligating  the  mesentery  of  the 
gangrenous  portion,  cutting  away  the  latter  and  leaving  the  ends  of  the  intes- 
tine open  for  drainage  and  leaving  the  construction  of  an  anastomosis  for 
future  consideration. 

Important  points.  The  points  which  should  be  impressed  especially  in  con- 
nection with  this  subject  are:  1.  The  necessity  of  always  making  a  physical 
examination  in  cases  suffering  from  intra-abdominal  pain,  nausea  or  vomiting, 
and  always  to  examine  for  hernia  in  these  cases  because  this  will  enable  the 
physician  to  make  an  early  diagnosis.  2.  The  necessity  of  relieving  the  stran- 
gulation at  once.  3.  The  fact  that  these  cases  are  more  likely  to  recover  if 
relieved  of  the  strangulation  early  by  a  clean  physician  or  surgeon  with  little 
or  no  experience,  than  by  a  surgeon  with  the  greatest  possible  skill  if  operated 
late. 

DIAPHRAGMATIC  HERNIA 

Diaphragmatic  hernias  are  very  rare  and  when  they  do  exist  are  seldom 
diagnosed  before  the  abdomen  is  opened.  The  majority  of  cases  that  have 
been  reported  have  been  found  post-mortem. 


378  GENERAL  SURGERY  OF  THE  ABDOMEN 

Diaphragmatic  hernia  may  be  congenital  or  acquired.  The  congenital 
variety  is  rarely  amenable  to  surgical  treatment,  because  so  great  a  portion 
of  the  diaphragm  is  absent  that  it  is  impossible  to  close  the  large  opening. 

The  acquired  variety  may  frequently  be  benefited  by  operation.  These 
herniiB  may  follow  stab  Avounds,  gunshot  wounds  and  crushing  injuries,  or 
the}'  may  develop  through  one  of  the  normal  openings  in  the  diaphragm  from 
any  cause  producing  an  increased  intra-abdominal  pressure.  The  most  fre- 
quent site  for  the  hernia  to  take  place  is  through  the  opening  of  the  esophagus. 

The  s3'mptoms  of  diaphragmatic  hernia  are  most  commonly  those  of 
strangulation  of  some  of  the  abdominal  viscera,  but  the  real  cause  of  the 
strangulation  is  rarely  diagnosed  until  the  abdomen  is  opened. 

There  can  be  no  definite  operation  planned  for  the  relief  of  these  cases. 
There  is  a  difference  of  opinion  among  surgeons  as  to  the  method  of  approach- 
ing such  a  hernia.  Some  advise  attacking  it  through  the  pleural  cavity,  while 
others  prefer  the  abdominal  route. 

In  man}"  of  these  cases  the  stomach  and  nearly-  all  of  the  intestines  are 
found  in  the  hernial  cavity. 

The. very  large  hernias  are  hopeless  as  far  as  closure  of  the  hernial  open- 
ing is  concerned.  In  two  cases  Mayo  was  able  to  close  the  hernial  opening 
by  suturing  the  wall  of  the  stomach  to  the  edges  of  the  opening  in  the  dia- 
phragm and  to  the  abdominal  wall  and  parietal  peritoneum  in  several  places. 
Both  patients  made  a  good  recovery. 

INTRA-ABDOMINAL  HERNIA 

In  text-books  little  is  said  of  intra-abdominal  hernias.  This  is  on  account 
of  their  infrequency.  They  do  occur,  however,  and  in  order  to  recognize 
them  an  understanding  of  their  location  is  essential.  The  intersigmoid  fossa 
is  found  on  the  under  surface  of  the  mesosigmoid  at  the  line  of  attachment 
of  the  mesosigmoid  to  the  abdominal  wall  and  just  about  the  point  of  emergence 
of  the  left  iliac  artery  from  beneath  the  mesentery  of  the  sigmoid  colon.  Six 
examples  of  large  hernias  into  this  fossa  are  recorded  in  the  literature. 

Three  fossa*  are  described  in  the  region  of  the  duodeno-jejunal  junction, 
the  superior  and  inferior  duodenal  fossae  and  the  paraduodenal  pouch  of 
Landzert.  Approximately  70  authentic  cases  of  hernia  in  one  of  these  pouches 
have  been  recorded  in  the  literature.  Of  these  9  were  operated  successfully. 
(Unusual  Internal  Hernias,  Nuzum,  F.  &  J.,  Trans.  Chi.  Path.  Soc-.,  Dec,  1914.) 

A  very  few  examples  of  hernia  into  pouches  about  the  cecum  of  the 
ileocecal  junction  have  been  described. 

The  treatment  of  each  of  these  types  of  hernia  consists  in  withdrawing 
the  loops  of  intestine  from  the  hernia  sac,  releasing  the  constriction  at  the 
mouth  of  the  sac  if  necessary,  but  being  cautious  not  to  cut  large  vessels 
which  frequently  are  found  in  the  mouth  of  the  sac.  The  opening  into  the 
sac  should  then  be  closed  in  some  manner. 

SPLEEN 

The  spleen  is  the  largest  of  the  ductless  glands  and  resembles  the  other 
members  of  this  group  in  that  there  is  very  little  definitely  known  concerning 
its  function.  It  is  evident,  however,  that  the  spleen  does  not  have  an  im- 
portant internal  secretion,  because  of  the  fact  that  its  removal  does  not 
deprive  the  body  of  any  important  constituent,  and  does  not  jeopardize  the 
life  or  comfort  of  the  individual  subsequentl3^  There  are  numerous  reports 
where,  in  cases  of  injury  of  the  spleen,  a  splenectomy  was  necessary,  and 
after  the  lapse   of  many  years  the  patient  had   apparently  suffered  no  ill 


GENERAL  SURGERY  OF  THE  ABDOMEN 


379 


effects  therefrom.  It  is  possible  that  after  removal  of  the  spleen,  its  Action 
's  taken  up  bv  other  organs,  especially  the  lymphatic  and  hemolymph  glands 
It  fs  also  possible  that  the  thymus  and  liver  may  compensate  to  some  extent 
for  the  loss  of  the  spleen,  as  changes  in  both  these  organs  have  been  noted 

'"^^t!  cEiiJS^faS'that  in  the  majority  of  patients  suffermg  from  infectious 


Showing  Vessels   of   Spleen   Clamped   by   Long   Forceps,   Ja^s   Protected   by   Ecbbeb 

Tubes.    (Mayo.) 

diseases,  the  spleen  is  enlarged,  often  to  the  extent  of  being  palpable.  The 
sio-nificance  of  this  enlargement  is  unknown,  but  it  has  been  suggested  that 
th°e  spleen  with  the  other  lymphatic  structures,  acts  as  a  barrier  thus  pro- 
tectino-  the  bodv  against  micro-organisms  and  their  products.  It  lias  also 
been  suo-o-ested  that  after  splenectomy  patients  are  more  susceptible  to  the 
current  infectious  diseases.  It  is  doubtful  whether  or  not  this  be  true.  It 
has  frequently  been  observed  that  the  resistance  agamst  infectious  diseases, 


380  GENERAL  SURGERY  OF  THE  ABDOMEN 

once  they  are  contracted,  is  not  evidentl}-  affected  by  splenectomy.  One  of 
the  writer's  patients,  who  had  been  splenectomized  seven  years  previously, 
contracted  pneumonia.  The  disease  terminated  favorably  in  the  usual  man- 
ner. Another  patient  whose  spleen  had  been  removed  six  months  previously, 
contracted  typhoid  fever,  running  a  typical  course  of  the  disease,  making 
fully  as  rapid  a  recovery  as  the  ordinary  case. 

Notwithstanding  the  fact  that  an  immense  amount  of  research  work  has 
been  done  regarding  the  physiology  and  function  of  the  spleen,  especially 
by  Pearce  and  his  co-workers,  one  is  impressed  with  the  confusion  that  still 
exists.  Very  little  has  been  attained  that  would  aid  us  in  determining  the 
course  of  treatment  in  diseases  apparently  due  to  abnormal  functioning  of 
the  spleen.  We  still  must  depend  mainly  upon  clinical  observations  to  guide 
us  in  the  procedures  to  be  pursued  in  these  cases.  AVith  the  increasing  num- 
ber of  splenectomies  during  the  past  four  years,  there  is  now  enough  clinical 
evidence  to  show  that  there  are  numerous  maladies  in  which  splenectomy 
may  be  indicated,  the  most  important  of  which  are  as  follows : 

SPLENIC  ANEMIA.   (BANTI'S  DISEASE) 

Banti  first  described  this  form  of  anemia,  the  characteristics  of  which  are 
a  primary  splenomegaly,  with  secondary  anemia,  later  followed  by  cirrhosis 
of  the  liver  and  ascites.  The  disease  is  a  chronic  affection,  with  a  progressive 
remittent  enlargement  of  the  spleen,  often  extending  over  a  period  of  many 
years.  The  etiology  of  the  disease  is  still  unknown.  The  onset  is  very 
insidious,  and  frequently  the  only  detectable  symptom  at  first  is  an  enlarge- 
ment of  the  spleen.  This  enlargement  may  be  present  for  several  years  without 
giving  rise  to  any  other  sj^mptoms,  even  the  blood  picture  remaining  normal. 
After  the  anemia  develops,  there  is  no  pathognomonic  change  in  the  blood 
picture.  It  is  an  anemia  of  the  secondary  type,  in  which  the  hemoglobin 
percentage  is  usually  correspondingly  lower  than  in  other  secondary  anemias. 
There  is  usually  a  leucopenia  present,  the  average  count  being  between  2,000 
and  5,000.  A  differential  count  of  the  white  cells  shows  no  characteristic 
changes.  One  of  the  rather  typical  features  of  the  disease  is  the  occurrence 
of  recurrent  hemorrhages  from  the  stomach.  It  is  not  uncommon  for  a  gastric 
hemorrhage  to  be  the  first  symptom  noted,  occurring  before  the  enlargement 
of  the  spleen  has  been  noticed.  Frequently  there  are  no  previous  symptoms, 
gastric  or  otherwise,  and  after  the  patient  recovers  from  the  immediate 
effects  of  the  hemorrhage,  which  may  have  been  severe,  he  may  again  become 
symptomatically  well. 

Treatment.  Temporary  improvement  can  usually  be  obtained  in  splenic 
anemia  by  drug  therapy,  the  arsenic  and  iron  compounds  being  chiefly  used. 
The  improvement  is  only  temporary,  as  the  sj^mptoms  are  certain  to  return. 
The  disease  being  primary  in  the  spleen,  splenectomy  naturally  seems  to  be 
the  rational  treatment.  During  the  past  few  years  a  comparatively  large 
group  of  cases  has  been  splenectomized,  the  results  of  which  have  been  very 
gratifying.  In  considering  the  treatment  it  is  important  to  bear  in  mind  that 
the  disease  is  primary  in  the  spleen,  with  a  chronic  enlargement,  and  that 
invariably  this  is  followed  by  cirrhosis  of  the  liver.  Furthermore,  that  re- 
moval of  the  spleen  not  only  relieves  the  anemia,  but  prevents  the  later 
development  of  cirrhosis  of  the  liver. 

Thus  it  is  important  that  a  splenectomy  be  made  early  in  the  disease, 
before  these  secondary  changes  have  taken  place.  Splenectomy  as  a  curative 
measure  has  been  so  definitely  established,  that  one  is  justified  in  saying  that 
removal  of  the  spleen  should  be  made  in  every  case  of  splenic  anemia  as  soon 
as  the  diagnosis  is  made.     Even  in  the  advanced  stages  of  the  disease,  with 


GENEEAL  SURGEHY  OF  THE  ABDOMEN  381 

cirrhosis  of  the  liver,  it  is  surprising  what  a  marked  improvement  follows 
splenectomy,  and  some  of  these  cases  are  even  apparently  cured.  Patients 
that  are  anemic  and  weak  stand  the  operation  remarkably  Avell.  If  the  anemia 
is  very  pronounced,  one  or  more  blood  transfusions  will  increase  the  patient's 
resistance  and  greatly  lessen  the  risks  of  the  operation. 

GAUCHER 'S  DISEASE 

This  rather  uncommon  disease  resembles  splenic  anemia  very  much;  in 
fact,  clinically  it  usually  cannot  be  differentiated  from  Banti's  disease.  It 
is  characterized  by  a  gradual  enlargement  of  the  spleen  with  development 
of  a  mild  secondary  anemia,  and  later  enlargement  of  the  liver.  Pathologically 
the  disease  diff'ers  from  splenic  anemia  in  that  the  enlarged  spleen  is  an 
endotheliomatous  growth,  and  later  in  the  disease  growths  of  the  same  char- 
acter are  found  in  the  liver  and  other  organs.  Gaucher  considered  the 
condition  a  primary  epithelioma  of  the  spleen,  but  AYilson,  at  the  Mayo  clinic, 
points  out  the  fact  that  it  fails  to  shoAV  the  attributes  of  malignancy,  but 
rather  a  form  of  hyperplasia  resembling  that  observed  in  the  thyroid.  This 
probably  explains  the  fact  why  the  prognosis  is  better  than  that  of  malignancy. 
It  has  been  shown  clinically  that  the  prognosis  is  good  following  a  compara- 
tively early  splenectomy. 

The  blood  picture  is  not  characteristic  and  resembles  that  of  splenic 
anemia.  There  is  a  relatively  slight  anemia,  with  a  progressive  decrease  of 
the  hemoglobin  percentage.  Leucopenia  is  usually  present  with  a  relative 
decrease  of  the  polynuclears. 

The  disease  is  more  common  in  women  than  in  men,  W'hile  splenic  anemia 
occurs  a  little  more  frequently  in  men  than  in  women.  Gaucher 's  disease 
usually  begins  before  the  thirtieth  year  and  runs  a  chronic  course,  often 
covering  a  period  of  twenty-five  years.  The  treatment  is  the  same  as  in 
splenic  anemia.  If  the  spleen  is  removed  before  terminal  changes  take  place 
in  other  organs,  the  prognosis  is  good  and  the  patients  are  apparently  cured. 

HEMOLYTIC  JAUNDICE 

Hemolytic  jaundice  is  a  chronic  disease  characterized  by  the  presence  of 
a  mild  chronic  icterus,  with  or  without  an  indefinite  weakness  and  malaise, 
with  intermittent  attacks  of  a  so-called  "crisis"  during  which  attacks  there 
is  a  marked  increase  in  size  and  tenderness  of  the  spleen,  accompanied  by  an 
intense  hemolysis,  and  malaise  and  usually  some  temperature.  The  jaundice 
becomes  quite  marked,  but  differs  from  obstructive  jaundice  in  that  there  is 
no  pruritus,  no  petechia,  and  is  of  a  light  lemon  color.  Bile  will  be  found 
freely  in  the  stools,  but  not  in  the  urine.  The  acute  symptoms  of  the  attacks, 
which  are  usually  spoken  of  as  bilious  attacks  by  the  patient,  usually  last 
from  two  to  four  weeks,  but  the  increased  icterus  may  persist  for  several 
months.  The  intervals  between  attacks  may  vary  from  a  few  months  to  a 
year  or  more.  A  marked  acute  secondary  anemia  results  from  each  crisis, 
varying  greatly  in  degree.  The  red  count  may  fall  as  low  as  one  million, 
but  as  soon  as  the  acute  symptoms  subside  usually  rises  rapidly  to  three  or 
four  million,  often  to  a  point  only  slightly  less  than  normal.  There  is  nothing 
characteristic  in  the  blood  picture. 

Hemolytic  jaundice  is  of  two  types,  the  acquired  and  the  familial  or 
congenital  type.  The  symptoms  in  the  congenital  type  differ  in  no  way  from 
the  acquired  type,  except  that  the  latter  progresses  more  rapidly,  the  crises 
are  more  severe  and  at  shorter  intervals,  the  disease  being  more  apt  to  result 
fatally.     In  the  familial  type,  the  symptoms  may  persist  for  years  or  a  life- 


382  GENERAL  SURGERY  OF  THE  ABDOMEN 

time,  the  patient  remaining  in  a  fair  degree  of  health,  although  suffering  at 
times  from  the  mild  crises  as  previously  described. 

Treatment.  Medical  treatment  has  failed  to  alter  or  ameliorate  the  condi- 
tion. On  the  other  hand,  the  results  from  splenectomy  have  been  so  good  that 
the  procedure  should  be  recommended  in  all  these  cases,  as  it  results  in  an 
apparent  cure  in  those  who  survive  the  operation.  The  choice  of  time  for 
splenectomy  in  hemolytic  icterus  is  important.  The  operation  should  not  be 
done  during  one  of  the  periods  of  crisis.  When  the  spleen  is  removed  in  the 
free  interval  between  the  crises,  the  mortality  should  be  extremely  low. 

SPLENOMEGALY  WITHOUT  ANEMIA 

While  splenomegaly  is  only  a  sign  of  one  of  many  disorders,  this  condition 
may  exist  for  many  years  without  any  apparent  injury  to  health.  In  some 
of  these  cases  the  only  symptom  present  is  that  of  enlarged  spleen,  which  in 
some  instances  becomes  so  large  as  to  be  a  great  burden  to  the  patient.  It  is 
likely  that  some  of  these  cases  are  really  a  mild  chronic  type  of  splenic 
anemia,  in  which  the  symptoms  are  so  slight  that  a  definite  diagnosis  cannot 
be  made.  In  this  type  of  case,  if  the  enlarged  spleen  cannot  be  reduced  in 
size  by  a  thorough  course  of  treatment  with  arsenic,  quinine  or  the  iodide  of 
potassium,  a  splenectomy  is  indicated. 

The  author  removed  the  spleen  in  this  type  of  case  seventeen  years  ago. 
The  patient  has  been  under  observation  frequently  since  that  time  and  has 
shown  no  ill  effects  from  the  loss  of  his  spleen.  Seven  years  after  the  opera- 
tion he  had  an  attack  of  pneumonia,  which  took  a  normal  course,  and  during 
this  attack  examination  of  his  blood  showed  the  same  condition  as  in  other 
cases  suffering  from  pneumonia  at  the  same  time  in  the  same  hospital  ward. 

SYPHILITIC  SPLENOMEGALY  ACCOMPANIED  BY  SECONDARY 

ANEMIA 

This  condition  may  simulate  splenic  anemia,  with  which  it  is  very  likely 
to  be  confused.  In  all  cases  of  splenomegaly  it  is  important  that  a  Wassermann 
test  should  be  made,  and  in  the  history  a  careful  search  made  for  any  evidence 
of  infection,  in  order  to  exclude  syphilis  as  far  as  possible. 

Mayo  first  called  attention  to  the  fact  that  in  some  of  these  cases  the 
symptoms  will  persist  in  spite  of  all  forms  of  anti-syphilitic  treatment,  until 
after  the  removal  of  the  enlarged  spleen,  when  the  anemic  symptoms  disap- 
pear and  the  Wassermann  test  remains  negative.  From  this  it  would  seem 
that  in  cases  of  splenomegaly  associated  with  syphilis,  the  symptoms  of 
which  are  not  relieved  by  thorough  anti-syphilitic  treatment,  a  splenectomy 
is  definitely  indicated. 

MALARIAL  SPLENOMEGALY 

The  spleen  becomes  acutely  congested  and  enlarged  during  an  attack  of 
malaria.  This  enlargement  disappears  after  the  attack  subsides,  but  in  some 
cases  repeated  attacks  result  in  a  permanent  enlargement  of  the  spleen,  often 
becoming  quite  large.  Malarial  splenomegaly  is  more  prone  to  rupture  than 
any  other  type  of  enlarged  spleen.  The  authors  have  found  that  practically 
all  of  these  cases,  even  when  the  spleen  is  very  large,  will  yield  to  the 
systematic  use  of  quinine  and  arsenic. 

The  former  remedy  should  be  given  in  solution  in  two-grain  doses  every 
two  hours  night  and  day  for  twenty-four  doses,  then  one-fiftieth  of  a  grain 
of  arsenious  acid  should  be  given  at  intervals  of  three  hours,  six  times  dailj^, 


GENERAL  SURGERY  OF  THE  ABDOMEN  383 

for  six  days,  then  the  course  of  twenty-four  two-grain  doses  of  quinine  should 
be  repeated.  This  method  insures  the  presence  of  fresh  quinine  in  the  body 
constantly  and  is  much  more  effective  in  these  chronic  cases  than  when  given 
in  larger  doses  at  longer  intervals ;  indeed,  many  cases  in  which  enormous 
doses  of  quinine  were  given  from  two  to  four  times  a  day  had  no  permanent 
effect  after  treatment  for  weeks  or  months,  have  recovered  after  a  few 
courses  of  treatment  by  this  method.  "V^'e  have  had  an  opportunity  of  testing 
this  method  in  a  large  number  of  cases  of  chronic  tropical  malaria  and  have 
found  it  absolutely  reliable.  It  is  well  to  give  these  patients  two  ounces  of 
castor  oil  in  the  foam  of  malt  or  beer  daily  during  this  course  of  treatment, 
in  order  to  ensure  perfect  absorption  of  the  remedies. 

Some  authorities  have  found  it  impossible  to  destroy  the  Plasmodium  in 
the  spleen  and  relieve  the  chronic  anemia  by  medication,  and  have  resorted 
to  splenectomy.  Jonnesco  reported  a  number  of  splenectomies  for  this  con- 
dition, with  the  result  that  all  the  patients  who  recovered  from  this  operation 
were  cured. 

TUBERCULOUS  SPLENOMEGALY 

The  spleen  may  be  the  seat  of  primary  tuberculosis,  but  it  more  often 
occurs  as  a  complication  of  general  tuberculosis,  especially  the  miliary  form. 
Cases  have  been  reported  in  which  the  tuberculous  spleen  was  followed  by 
general  hyperplasia  of  the  lymphatic  tissues.  In  such  instances  the  condition 
is  apt  to  be  mistaken  for  a  lymphadenoma.  The  blood  picture  is  not  at  all 
characteristic.  The  author  encountered  one  case  of  tuberculosis  of  the  spleen, 
which  was  apparently  primary,  the  only  symptoms  being  general  weakness, 
considerable  tenderness  and  some  pain  in  splenic  area,  spleen  extending  about 
three  fingers  below  costal  margin.  Slight  afternoon  temperature  was  present. 
The  blood  picture  was  one  of  a  mild  secondarj^  anemia.  Removal  of  the 
spleen  showed  numerous  tuberculous  nodules  and  caseous  masses  with  areas 
of  fibrosis.  It  is  now  seven  months  since  the  operation :  the  patient  has  ex- 
hibited no  signs  of  tuberculosis  elsewhere,  and  general  health  is  good. 

CHRONIC  SPLENITIS 

This  is  not  an  luicommon  condition  and  may  occur  as  a  complication  of 
various  infectious  diseases.  The  spleen  is  generally  supposed  to  collect  various 
parasites  and  send  them  to  the  liver  for  destruction.  Under  certain  conditions 
the  spleen  does  not  seem  able  to  rid  itself  of  these  infections,  which  results 
in  a  chronic  splenitis  and  splenomegaly.  This  condition  is  practically  always 
associated  with  a  perisplenitis.  There  is  usually  quite  marked  enlargement 
of  the  spleen,  and  considerable  discomfort  and  pain  in  the  splenic  area,  radi- 
ating in  various  directions.  The  pain  is  aggravated  by  pressure,  such  as  lying 
on  the  left  side,  and  is  often  aggravated  by  deep  breathing.  Exacerbation  of 
the  symptoms  and  splenomegaly  are  quite  common,  the  interval  varying  from 
a  few  weeks  to  several  months.  The  blood  picture  may  be  practically  normal 
or  one  of  a  mild  secondary  anemia.  It  is  the  author's  experience  that  the 
chronic  recurrent  splenitis  does  not  yield  to  medical  treatment,  and  eventually 
has  to  come  to  operation.  The  results  from  splenectomy  in  our  hands  have 
been  excellent. 

WANDERING  SPLEEN 

Occasionally  a  spleen  will  become  extremely  movable  so  that  it  may  be  dis- 
located to  all  parts  of  the  abdominal  cavity.     This  may  be  accompanied  by  a 


384  GENERAL  SURGERY  OF  THE  ABDOMEN 

considerable  amount  of  suffering  in  the  form  of  acute  pain  and  digestive  dis- 
turbances. 

In  these  cases  the  phreno-splenic  ligament  is  drawn  out  so  that  it  no  longer 
serves  as  a  support,  and  the  other  peritoneal  support  is  equally  useless.  This 
pedicle  may  become  twisted  and  may  give  rise  to  severe  pain  or  even  collapse. 
It  may  give  rise  :to  a  diagnosis  of  acute  mechanical  obstruction  of  the 
intestines. 

Operation.  The  outer  edge  of  the  wound  is  retracted  thoroughly  and  a  pouch 
formed  out  of  the  parietal  peritoneum  and  transversalis  fascia  sufficiently  large 
to  conveniently  hold  the  spleen  which  is  sutured  in  place.  What  is  left  of  the 
phreno-splenic  ligament  is  utilized  in  fastening  the  spleen  in  this  position. 
In  performing  this  operation  care  should  be  taken  not  to  do  anything  which 
might  interfere  with  the  blood  vessels  in  the  gastro-splenic  omentum. 

In  case  the  pedicle  has  been  twisted,  or  the  operation  just  described  does 
not  promise  permanent  relief,  it  is  best  to  remove  the  organ,  which  can  be 
done  wdth  the  greatest  ease  in  these  cases  by  simply  ligating  the  pedicle  and 
cutting  it  off  two  cm.  beyond  the  ligature. 

These  patients  do  not  suffer  from  the  loss  of  this  organ. 

PERNICIOUS  ANEMIA 

Pernicious  anemia  is  a  recent  acquisition  to  the  field  of  surgery,  but  there 
is  not  sufficient  evidence  yet  to  say  that  any  case  of  pernicious  anemia  has 
been  cured  by  surgery  alone.  It  is  evident  that  the  essential  pathological  pro- 
cess is  not  in  the  spleen,  yet  there  is  enough  clinical  evidence  to  show  that  the 
spleen  may  be  a  factor  of  considerable  importance. 

In  the  study  of  sixty  cases  of  pericious  anemia,  we  have  been  impressed 
with  the  importance  of  a  few  signs  and  symptoms  as  found  in  these  cases. 

(a)  Hydrochloric  acid.  In  all  cases  in  which  the  test  was  made,  with  one 
exception,  a  complete  absence  of  free  hydrochloric  was  found  in  the  fasting 
contents  and  in  the  specimens  of  test  meal.  The  exception  Avas  a  very  early 
case  and  showed  a  very  low  hydrochloric  acid  content.  A  few  cases  were  in 
such  an  extreme  condition  that  it  was  not  deemed  advisable  to  subject  them 
to  the  strain  of  passing  a  stomach  tube.  The  absence  of  free  hydrochloric  acid 
occurred  with  such  regularity  that  one  w^ould  hesitate  to  make  a  diagnosis  of 
pernicious  anemia  in  any  case  showing  hydrochloric  acid,  unless  it  be  a  very 
early  case  and  the  acid  count  very  low.  At  the  Peter  Bent  Brigham  Hospital 
in  Boston  several  cases  were  worked  up  and  found  to  have  an  anacidity. 
The  blood  was  carefully  examined,  including  estimation  of  hemoglobin  per- 
centage, a  red,  white  and  differential  count,  and  found  negative.  Subse- 
quently, these  cases  returned  to  the  hospital  with  well-defined  pernicious 
anemia. 

(b)  Tongue.  The  appearance  of  the  tongue  was  noted  in  every  case, 
which  revealed  a  peculiar,  smooth,  glassy  surface.  In  some  cases  this  appear- 
ance was  present  only  on  the  sides  of  the  tongue.  This  condition  of  the 
tongue  is  one  of  the  most  important  external  signs  of  pernicious  anemia. 

(c)  Pigmentation.  Pigmentation  was  found  to  be  present  in  the  majority 
of  cases,  especially  on  the  backs  of  the  hands.  The  pigmentation  may  be 
diffuse  or  freckle-like. 

(d)  Hypertension  (chronic  nephritis)  frequently  coexists  with  pernicious 
anemia.  A  high  blood  pressure  was  found  in  the  majority  of  patients  of 
middle  age  or  beyond.  The  hypertension  persists,  but  not  quite  as  marked, 
through  periods  of  severe  weakness,  only  letting  down  when  the  patient  be- 
comes extremely  ill.     For  instance,  it  was  noted  in  a  patient  in  the  terminal 


GENERAL  SURGERY  OF  THE  ABDOMEN  385 

stage,  that  the  systolic  pressure  dropped  from  230  to  80  in  three  days,  death 
resulting  on  the  fourth  day. 

(e)  Temperature.  The  finding  of  temperature,  of  a  septic,  picket-fence 
type,  was  quite  common.  When  this  is  accompanied  by  diarrhea  it  is  a  very 
grave  symptom. 

(f )  Diarrhea  and  vomiting.  Diarrhea  and  vomiting  was  noted  frequently 
and  found  difficult  to  control  by  medical  means.  These  cases  yielded  readily 
by  being  given  a  transfusion  of  600-800  c.c.  of  blood,  followed  by  the  adminis- 
tration of  large  doses  of  hj^drochloric  acid  and  bismuth.  The  vomiting 
invariably  stopped  immediately  following  the  transfusion,  and  the  diarrhea 
usually  subsided  within  a  few  days.  In  a  few  instances  attacks  of  diarrhea 
was  the  first  symptom  of  the  disease  noted  by  the  patient. 

(g)  Nerve  symptoms.  The  nerve  symptoms  noted  were  many  and  varied, 
ranging  from  the  most  common,  that  of  tingling  in  the  fingers  and  toes,  to 
those  simulating  tabes  and  multiple  sclerosis.  Marked  psychical  disturbances 
were  also  noted  in  some  cases. 

The  tongue  sign,  the  pigmentation  and  the  hydrochloric  acid  test  occur 
with  such  constancy  that  their  presence  may  often  be  the  deciding  factors 
in  the  diagnosis  in  which  the  blood  picture  is  a  border-line  one. 

Etiology.  While  the  etiology  and  pathogenesis  of  pernicious  anemia  is 
still  a  perplexing  problem,  it  seems  evident  that  besides  a  condition  of  in- 
creased hemolysis,  there  is  some  toxic  action  on  the  bone-marrow.  From  our 
study  of  these  cases  we  have  been  impressed  with  the  value  of  the  observa- 
tions of  Hunter,  with  respect  to  the  toxic,  or  even  infectious,  nature  of  the 
disease. 

All  of  our  cases  have  been  studied  for  the  existence  of  a  chronic  infection, 
and  in  practically  every  one  infective  foci  were  demonstrable.  The  regions 
in  which  foci  were  found  are  namely:  The  gall-bladder,  appendix,  and  about 
the  mouth  and  throat.  Just  what  effect  this  chronic  low  grade  infection  may 
have  upon  the  hematopoietic  organs,  is  still  an  unanswered  question.  The 
spleens  removed  have  shown  evidence  of  a  chronic  splenitis  and  usually 
perisplenitis,  indicating  that  a  toxic  or  infective  process  had  been  present  there. 

Treatment.  In  view  of  the  fact  that  pernicious  anemia  is,  in  all  proba- 
bility, a  disease  of  infectious  origin,  and  that  the  spleen  has  abnormal 
hemolytic  action  on  the  blood  elements,  with  a  late  bone-marrow  exhaustion, 
we  have  been  more  and  more  firmly  convinced  that  the  rational  treatment  in 
selected  cases  consists  of  three  main  factors,  viz. :  (a)  massive  step-ladder  trans- 
fusions of  whole  blood,  (b)  splenectomy,  and  (c)  removal  of  all  possible 
sources  of  infection. 

Each  of  these  steps  plays  an  important  part  in  the  treatment.  The  repeated 
blood  transfusions  nourish  and  stimulate  the  bone-marrow  to  action  and  help 
to  restore  the  secondary  changes  in  the  various  organs ;  the  splenectomy 
unquestionably  reduces  the  amount  of  blood  destruction ;  and  the  removal  of 
the  various  foci  of  infection  will  relieve  the  patient  of  a  chronic  toxemia,  and 
possibly  of  an  etiological  factor  of  the  disease. 

Indications  for  operation.  In  analyzing  the  various  patients  that  have 
been  splenectomized,  it  is  evident  that  certain  cases  are  unsuitable  for  opera- 
tion. The  degree  of  anemia  present  is  of  less  importance  in  determining 
operation  than  the  clinical  manifestations  of  the  disease.  Patients  showing 
nervous  or  mental  symptoms  or  evidence  of  pathological  changes  in  the  spinal 
cord,  probably  should  not  be  considered  as  surgical.  While  in  these  cases  the 
blood  picture  will  often  be  improved  for  a  considerable  time,  it  does  not  seem 
to  interrupt  the  degeneration  that  is  taking  place  in  spinal  cord  and  central 
nervous  system.  Splenectomy  should  not  be  attempted  during  an  exacerba- 
tion of  the  disease,  especially  if  this  be  accompanied  by  a  severe  diarrhea, 


386  GENERAL  SURGERY  OF  THE  ABDOMEN 

which  is  often  the  case.  In  the  majority  of  cases,  however,  by  a  series  of 
blood  transfusions,  the  exacerbation  can  be  rapidly  changed  so  that  in  three 
to  five  weeks  the  case  will  be  suitable  for  operation.  Patients  with  tempera- 
ture, recent  hemorrhage,  or  purpuric  eruption,  should  not  be  operated  unless 
these  symptoms  disappear  following  a  series  of  blood  transfusions. 

Operation  should  be  considered  in  all  other  patients  as  soon  as  a  positive 
diagnosis  of  pernicious  anemia  is  made,  and  all  conditions  which  might  be  a 
factor  in  producing  anemia,  which  can  independently  be  relieved,  have  been 
excluded. 

The  transfusion  of  blood  has  recently  received  a  great  deal  of  attention 
and  has  been  advocated  by  some  as  the  sole  means  of  treating  pernicious 
anemia.  Its  employment  will  result  in  marked  temporary  improvement  in 
the  vast  majority  of  cases.  Our  experience  has  been  that,  while  the  blood 
picture  will  improve  immediately  in  practically  every  case,  and  that  in  some 
early  cases  a  very  prompt  and  marked  remission  will  take  place  and  may 
persist  for  a  period  of  several  months,  on  the  other  hand,  in  the  late  cases, 
the  improvement  in  the  blood  picture  from  the  transfusion  alone  is  very 
transitory,  as  the  blood  will  begin  to  decline  within  a  period  of  two  to  three 
weeks,  unless  transfusion  is  repeated. 

The  immediate  effects  of  transfusion  are  usually  quite  striking.  The  red 
blood  count  is  increased,  often  doubling  immediately  if  the  count  is  very 
low ;  the  hemoglobin  percentage  rises,  and  the  number  of  platelets  is  in- 
creased. The  blast  cells  usually  become  more  numerous,  and  occasionally 
Howell's  particles  will  appear  in  the  blood,  indicating  a  stimulation  of  the 
bone-marrow. 

It  is  evident  that  the  transfusion  of  large  masses  of  whole  blood  accom- 
plishes more  than  the  mere  mechanical  addition  of  so  much  blood.  It  seems 
that  it  actually  exerts  either  a  curbing  influence  upon  the  hyperactive  spleen, 
or  a  stimulating  action  upon  the  bone-marrow,  since  the  blood  picture  con- 
tinues to  improve  for  several  days  after  transfusion.  This  may  be  due  to  the 
fact  that  the  blood-forming  organs  are  not  only  overworked,  but  are  also 
undernourished.  Furthermore,  the  multiple  blood  transfusions  supply  pro-, 
tective  antibodies  and  assist  the  patient  in  getting  rid  of  the  secondary 
changes  which  have  taken  place  in  the  various  organs.  During  the  period 
that  the  patient  is  being  prepared  for  operation  by  multiple  blood  trans- 
fusions, he  should  be  treated  in  regard  to  any  self-evident  infection. 

The  patients  begin  to  improve  immediately  after  the  first  transfusion,  and 
continue  to  improve  with  each  subsequent  one,  until  they  are  good  surgical 
risks,  and  splenectomy  can  be  done  without  greater  shock  than  would  be 
produced  in  any  other  patient  by  an  operation  of  the  same  magnitude. 

From  the  study  of  the  numerous  cases  of  pernicious  anemia  that  have 
been  operated  during  the  past  four  years,  it  is  evident  that  removal  of  the 
spleen  stops  only  temporarily  the  progress  of  the  disease  in  the  vast  majority 
of  cases.  The  authors  have  had  one  patient  in  whom  there  has  been  no  return 
of  symptoms  three  and  one-half  years  after  splenectomy,  and  four  others 
without  recurrence  of  symptoms  a  little  over  two  years  since  operation. 

While  no  surgeon  can  say  that  a  cure  has  resulted  from  splenectomy  or 
other  surgical  procedures  in  any  case  of  pernicious  anemia,  still  there  is 
enough  clinical  evidence  to  show  that  the  benefits  derived  from  surgery  are 
more  than  by  any  other  means.  This  evidence,  and  the  comparatively  low 
operative  mortality,  together  with  the  utter  failure  of  other  means  to  combat 
the  progress  of  the  disease,  are  all  strong  arguments  for  classing  pernicious 
anemia  as  a  surgical  disease. 


'  GENERAL  SURGERY  OF  THE  ABDOMEN         387 
SPLENOMYELOGENOUS  LEUKEMIA 

This  condition,  which,  has  always  been  looked  upon  as  a  hopeless  medical 
disease,  is  just  beginning  to  attract  attention  in  the  field  of  surgery.  The 
fact  that  the  application  of  the  X-ray  over  the  spleen  will  not  only  reduce 
the  enlarged  spleen  rapidlj'^,  but  will  also  decrease  the  white  cells  and  improve 
the  anemia,  has  suggested  the  idea  that  splenectomy  might  be  of  benefit  in 
these  cases.  Radium  applied  at  several  points  over  the  enlarged  spleen  has  a 
much  more  rapid  effect  than  the  X-ray.  The  relief  is  only  temporary,  both 
from  the  X-ray  and  radium,  for  as  soon  as  the  improvement  produced  by  the 
X-ray  or  radium  ceases,  the  increase  in  white  cells  and  enlargement  of  spleen 
will  recur.  Later  on,  after  one  or  more  exacerbations,  the  X-ray  and  radium 
both  lose  their  power  to  bring  about  another  remission  of  the  disease.  Dur- 
ing the  past  year  a  few  cases  have  been  treated  by  first  reducing  the  enlarged 
spleen  and  lowering  the  white  count  by  means  of  X-ray  or  radium,  or  by 
both  combined,  and  then  removing  the  spleen.  The  immediate  results  have 
been  satisfactory  so  far.  Time  is  too  short  to  predict  how  long  this  improve- 
ment may  last. 

The  authors  recently  encountered  a  case  of  splenomyelogenous  leukemia  in 
which  the  spleen  extended  well  into  the  pelvis,  and  the  white  count  was 
1,100,000.  Prom  the  use  of  radium  the  spleen  reduced  very  rapidly  in  size, 
and  the  white  count  dropped  from  1,100,000  to  15,000  within  eight  weeks.  A 
splenectomy  was  then  made,  the  patient  making  a  rapid  immediate  recovery. 
Time  is  too  short  to  predict  what  will  be  the  ultimate  outcome  in  this  case. 

Technique  of  operation.  In  pernicious  anemia  and  other  conditions  where 
the  spleen  is  not  large,  we  elect  the  high  mid-line  incision  instead  of  the 
usual  left  rectus,  for  the  reason  that,  first,  other  pathological  conditions,  such 
as  the  gall-bladder,  appendix,  gastric  ulcer,  etc.,  may  be  dealt  with ;  second, 
this  incision  can  extend  higher  than  any  other,  namely,  to  the  ensiform  car- 
tilage ;  and  third,  the  pedicle  and  blood  supply  of  the  spleen  are  readily 
accessible,  since  their  course  is  from  the  mid-line  towards  the  left,  thus 
enabling  one  to  reach  them  under  the  spleen's  edge,  without  having  to  pull 
the  spleen  outside  of  the  abdomen.  The  pedicle  of  the  spleen  in  pernicious 
anemia  is  usually  short,  and  there  is  less  danger  of  tearing  its  veins  if  it  is 
pulled  toward  the  mid-line  as  it  is  dislocated  and  lifted  from  its  bed.  If  the 
spleen  is  extremely  large,  it  is  preferable  to  make  the  incision  through  the 
left  rectus  muscle. 

Having  opened  the  abdomen  through  an  ample  incision,  a  thorough  ex- 
ploration of  the  abdominal  organs  should  be  made,  noting  the  condition  of 
the  appendix,  gall-bladder  and  bile  passages.  Any  pathological  conditions 
found  in  these  regions  should  be  dealt  with  as  in  any  other  patient, 

A  large  abdominal  pad  is  placed  in  the  left  upper  quadrant  of  the  abdomen, 
keeping  the  colon  and  small  intestines  from  the  field  of  operation.  The 
dislocation  of  the  spleen  from  its  location  against  the  diaphragm  and  left 
kidney  is  easily  accomplished  by  gently  passing  the  fingers  between  the 
spleen  and  these  structures,  keeping  the  fingers  in  close  contact  to  the  spleen 
surface  during  the  manipulation.  As  the  spleen  is  dislocated  it  is  gently 
rolled  toward  the  mid-line,  and  a  hot,  moist  pack  is  placed  in  the  space  from 
which  the_  spleen  has  been  lifted,  to  control  any  bleeding,  until  the  rest  of 
the  operation  is  completed.  The  hemorrhage  from  the  adhesions,  even  though 
considerable,  in  some  cases,  is  easily  controlled  in  this  manner.  In  mobilizing 
the  spleen  the  tail  of  the  pancreas  should  be  kept  in  mind,  as  it  is  occasionally 
adherent  to  the  under  surface  of  the  spleen  and  also  to  its  pedicle  along  its 
posterior  surface.  After  the  spleen  has  been  elevated,  the  gastro-splenic 
omentum  is  caught  between  forceps  and  ligated.     At  the  lower  pole  of  the 


388  GENERAL  SURGERY  OF  THE  ABDOMEN 

spleen  this  is  very  simple ;  at  the  upper  pole,  where  it  contains  the  vasa-brevia, 
several  in  number,  as  they  run  from  the  splenic  artery  to  the  greater  curva- 
ture of  the  stomach,  it  is  much  more  difficult.  The  edge  of  the  spleen  is  fre- 
quently in  close  apposition  with  the  fundus  of  the  stomach  in  this  region. 
As  soon  as  the  vasa-bevia  have  been  ligated,  the  fundus  of  the  stomach  can 
be  depressed  and  the  pedicle  of  the  spleen  readily  caught  Avith  two  pair  of 
forceps,  the  blades  of  which  are  covered  with  rubber  tubing.  The  pedicle  is 
now  transfixed  with  heavy  catgut  and  ligated  en  masse.  The  gauze  pack  is 
now  removed  from  the  space  where  the  spleen  was  located,  and  if  any  bleeding 
persists  from  the  small  vessels  torn  while  separating  the  adhesions,  they  are 
stitched  with  fine  catgut.  The  abdomen  is  closed  without  drainage.  If  the 
patient  is  extremely  anemic,  a  transfusion  of  600  to  800  c.c.  of  blood  is  given 
immediately  at  the  close  of  the  operation. 

PANCREATITIS 

Since  the  surgeon  has  come  to  consider  pancreatitis  habitually  with  the 
same  uniform  system  that  he  considers  all  other  important  intra-abdominal 
pathologic  conditions,  our  appreciation  of  its  importance,  as  well  as  our  knowl- 
edge of  this  condition,  has  acquired  reasonable  dimensions. 

Etiology.  Undoubtedly,  the  infection  usually  travels  up  the  common  duct 
into  the  gall-bladder  where  there  is  a  possibility  for  the  accumulation  of  a 
large  quantity  of  infected  bile  mixed  with  mucus,  which  on  its  way  down  the 
common  duct  is  easily  diverted  into  the  pancreatic  duct  if  there  is  obstruc- 
tion from  gall-stones  or  edema  below  the  point  at  which  the  duct  of  Wirsung 
empties  into  the  common  duct. 

In  our  cases  the  irritation  of  the  common  duct  has  been  due  quite  as  often 
to  the  passage  of  infected  sandy  bile  as  to  the  presence  of  gall-stones. 

There  is  much  difference  in  the  statistics  of  various  authors  regarding  the 
relative  frequency  with  which  pancreatitis  accompanies  gall-stones.  This 
is  probably  due  to  the  fact  that  the  diagnosis  of  pancreatitis  is  based  on  the 
impression  the  surgeon  obtains  from  palpating  the  gland  during  operation, 
and  one  surgeon  may  consider  the  gland  practically  normal  in  an  individual 
instance  in  which  the  same  condition  would  impress  another  surgeon  as  rep- 
resenting a  certain  degree  of  enlargement. 

Unless  a  surgeon  has  examined  many  cases  in  which  the  abdomen  was 
opened  for  conditions  which  could  have  no  relation  with  the  pancreas,  in 
order  to  become  familiar  with  the  feeling  of  a  normal  pancreas,  it  is  not  likely 
that  his  judgment  in  this  matter  can  be  entirely  satisfactory. 

It  is  therefore  well  to  palpate  the  pancreas  in  cases  of  operation  for  the 
removal  of  uterine  fibroids  or  ovarian  cysts  and  other  similar  conditions. 
This  can  be  done  readily  while  the  surgeon's  hand  is  in  the  upper  portion  of 
the  abdomen  for  the  purpose  of  examining  the  gall-bladder. 

All  surgeons  with  large  experience  in  this  special  direction  seem  to  agree 
that  pancreatitis  patients  almost  invariably  suffer  from  disease  of  the  gall- 
bladder or  ducts,  and  that  gall-stones  in  the  common  duct  are  more  commonly 
accompanied  by  pancreatitis  than  stones  in  the  gall-bladder. 

It  has  been  suggested  by  Williams  and  Bush,  and  apparently  confirmed 
by  careful  experimentation,  that  anatomic  peculiarities  interfering  with  the 
free  drainage  of  pancreatic  juice  through  the  ducts  of  Santorini  or  Wirsung 
provide  iavorable  conditions  for  the  infection  of  the  pancreas.  _  It  is  plain 
that  when  the  natural  conditions  for  free  drainage  of  pancreatic  juice  are 
unfavorable,  complete  obstruction,  due  to  the  presence  of  gall-stones  or 
edema,  is  much  more  likely  to  occur. 


GENERAL  SURGERY  OF  THE  ABDOMEN  389 

The  colon  bacillus  is  the  most  common  cause  of  the  infection,  and  is 
frequently  associated  with  the  streptococcus  and  the  staphylcoccus. 

Pancreatitis,  in  common  with  all  inflammatory  diseases  of  the  gall-bladder 
and  ducts,  frequently  follows  intiammatory  diseases  of  the  gastro-intestinal 
tract. 

After  the  pancreas  has  once  been  infected  a  species  of  vicious  circle  is 
developed  from  the  fact  that  the  swollen  pancreas  obstructs  the  portion  of 
the  common  duct  which  passes  through  the  head  of  this  organ,  which  favors 
the  development  of  septic  micro-organisms  above  this  point  as  well  as  their 
further  backing  up  into  the  pancreas.  It  is  for  this  reason  that  the  free  drain- 
age due  to  cholecystostomy  has  given  such  uniformly  favorable  results. 

All  these  facts  seem  to  bear  out  the  theory  commonly  accepted  at  the  pres- 
ent time  that,  barring  the  rare  occurrence  of  metastatic  infection,  j)ancreatitis 
is  due  to  infection  from  the  alimentary  canal,  usually  through  the  biliary 
passages,  or,  according  to  Maugaret,  more  especially  through  the  lymphatic 
system  of  these  passages.  The  acute  violent  cases  of  hemorrhagic  pancreatitis 
are  apparently  due  to  retrograde  injection  of  the  pancreas  with  infected  bile 
and  pancreatic  juice  which,  according  to  Flexner,  must  be  in  a  relatively  con- 
centrated form.  In  these  cases  which  take  a  violent  acute  course  there  is 
commonly  a  rapid  destruction  of  the  gland  parenchyma.  In  the  chronic  forms, 
on  the  other  hand,  the  inflammation  results  in  interlobular  fibrous  tissue  hyper- 
plasia. The  secreting  cells  of  the  acini  are  more  readily  destroyed  than  the 
islands  of  Langerhans.  This  fact  would  account  for  the  relative  infrequency 
of  glycosuria  in  mild  or  early  cases  of  pancreatitis. 

Diagnosis.  Until  recently  the  diagnosis  of  pancreatitis  was  made  incident- 
ally only  during  the  progress  of  operations  on  the  gall-bladder  or  biliary  tracts 
and  the  stomach.  Since  the  attention  of  surgeons  was  generally  directed  to 
this  condition  by  Mayo  Robson,  Riedel,  Mayo  and  others,  the  diagnosis  has 
frequently  been  made  before,  and  confirmed  during,  the  operation.  From 
this  it  has  become  possible  to  associate  the  condition  of  pancreatitis  with  a 
number  of  more  or  less  typical  diagnostic  signs  observed  before  operation. 

In  1904  Cammidge,  in  connection  with  the  clinical  work  of  Mayo  Robson, 
brought  out  a  most  ingenious  chemical  test  which  promised  to  be  of  great 
value  in  the  diagnosis  of  this  condition. 

The  method  has  been  described  most   clearly  by  Schroeder,   as  follows : 

Forty  c.c.  of  the  urine,  filtered,  acid  reaction,  free  from  albumin  and 
sugar,  are  boiled  with  2  c.c.  of  strong  hydrochloric  acid  for  ten  minutes. 
After  partly  cooling,  80.0  gm.  of  lead  carbonate  are  gradually  added.  "When 
the  reaction  is  complete,  the  mixture  is  chilled,  filtered  and  the  excess  of 
lead  in  solution  removed  by  addition  of  2  gm.  of  sodium  sulphate  bringing 
the  mixture  to  a  boil,  chilling  and  filtering  to  20  c.c.  To  this  filtrate  is  now 
added  a  mixture  of  phenylhydrazin  hydrochlorate  0.80  gm.,  sodium  acetate 
2.0  gm.  and  of  50  per  cent,  glacial  acetic  acid  1  c.c.  and  the  whole  is  boiled 
on  a  sand-bath  for  ten  minutes.  The  solution  is  then  filtered  while  hot  and 
set  aside  to  crystallize.  The  precipitation  of  crystals,  sometimes  only  in 
microscopic  quantities,  of  the  characteristic  formation  of  ozazones,  makes  a 
positive  reaction. 

In  1905  we  had  a  large  number  of  tests  made  at  the  Augustana  Hospital 
laboratory  on  patients  who  were  later  operated  on,  so  that  the  findings  could 
be  judged  as  to  their  reliability  by  the  actual  examination  of  the  pancreas. 
These  tests  were  carried  out  by  Dr.  J.  L.  Yates,  then  chief  assistant,  whose 
large  experience  as  a  carefully  trained  laboratory  investigator  fitted  him 
particularly  for  this  task.  He  had,  moreover,  assisted  in  the  diagnosis,  opera- 
tion and  after-treatment  of  a  great  number  of  cases  belonging  to  this  special 
group,  so  he  also  possessed  a  large  experience  as  a  clinical  surgeon. 


390  GENERAL  SURGERY  OF  THE  ABDOMEN 

These  tests  were  extremely  fascinating,  but  it  seemed  to  us  that  it  required 
too  much  of  the  personal  element  of  the  observer  to  make  the  method  useful 
except  in  the  hands  of  unusually  skillful  experts. 

The  fact  that  surgeons  like  Robson  and  Moynihan  continue  to  trust  this 
test  is,  however,  sufficiently  important  to  convince  us  that  it  contains  real 
merit. 

Symptoms.  If  we  add  to  the  well-known  symptoms  of  cholecystitis  an  area 
of  tenderness  from  5  to  10  cm.,  long,  located  to  the  right  of  the  umbilicus 
over  the  middle  of  the  right  rectus  abdominis  muscle,  in  cases  in  which  we 
can  exclude  a  diagnosis  of  duodenal  ulcer,  we  have  the  typical  symptoms 
on  which  to  make  a  diagnosis  of  pancreatitis. 

In  duodenal  ulcers  there  are  two  symptoms  usually  present  which  are  not 
symptoms  of  pancreatitis:  (1)  pain  before  meals  when  the  stomach  is  empty, 
and  (2)  hyperchlorhydria  with  eructations. 

In  pancreatitis  there  is  frequently  referred  pain  to  the  mid-scapular  or 
left  scapular  regions.  In  gastric  ulcer  the  same  pain  is  commonly  present, 
but  with  this  there  is  pain  on  deep  pressure  at  a  point  half-way  between  the 
ensiform  appendix  of  the  sternum  and  the  umbilicus. 

There  are,  of  course,  cases  in  w^iich  two  or  more,  or  all  of  these,  condi- 
tions are  present  in  the  same  patient,  and  other  cases  in  which  it  is  possible 
only  to  determine  the  fact  that  one  or  more  of  these  conditions  are  present, 
while  a  strict  differential  diagnosis  may  not  be  possible.  In  these  cases,  how- 
ever, it  is  quite  possible  to  determine  the  necessity  of  an  exploratory  incision, 
and,  when  the  indications  for  this  are  not  clear,  then  it  is  usually  safe  to  keep 
the  patient  under  dietetic  treatment  until  further  study  has  cleared  up  the 
diagnosis. 

Solomon  has  pointed  out  the  fact  that  in  the  presence  of  pancreatitis 
von  Noorden's  oatmeal  diet  gives  rise  to  typical  butter  stools  and  that  an 
abnormally  large  amount  of  lecithin  is  excreted.  Prom  0.4  to  1.2  gm.  is  ex- 
creted in  twenty-four  hours  when  these  patients  are  placed  on  an  egg  diet, 
while  normal  individuals  excrete  not  to  exceed  0.1  gm.  under  similar  feeding. 

According  to  Schlecht,  Mueller's  test  is  quite  reliable.  The  patient  is 
given  a  test  meal  which  is  followed  after  two  hours  by  a  calomel  purge. 
A  few  drops  of  the  stool  are  sterilized  by  heat,  then  placed  on  an  agar  plate 
containing  Loeffer's  serum.  The  plates  are  kept  in  an  oven  at  131  to  141°  F. 
for  twenty-four  hours.  If  trypsin  is  present  the  serum  shows  pronounced 
depressions,  if  absent  the  surface  is  smooth.  Lepine  has  made  most  interest- 
ing but  very  complicated  experiments  which  he  claims  are  valuable  in  the 
diagnosis  of  this  condition. 

In  advanced  cases  there  is  usually  marked  emaciation,  frequently  with 
peculiar  circumscribed  areas  of  fat  in  roll-like  masses  on  the  front  and  sides  of 
the  chest  and  abdomen.  There  is  usually  marked  anemia  present,  often 
approaching  chlorosis  with  degeneration  of  the  erythrocytes.  Many  of  these 
patients  suffer  from  obstinate  constipation,  while  others  have  equally  trouble- 
some diarrhea. 

Sugar  is  present  in  the  urine  of  only  a  small  proportion  of  these  cases. 

Treatment  of  chronic  pancreatitis.  The  treatment  must  consist  primarily 
in  relieving  the  irritation,  due  to  the  backing  up  of  infected  bile,  by  establish- 
ing free  drainage  which  must  be  sufficiently  permanent  to  permit  complete 
restoration  of  gall-bladder  and  ducts,  as  well  as  the  pancreatic  ducts.  It  is 
important  to  keep  the  intestines  and  stomach  normal  and  free  from  irritation 
permanently  by  the  use  of  proper  diet  and  hygiene  after  these  operations. 

In  case  gall-stones  or  pancreas  stones  are  present,  these  must  be  removed, 
whatever  their  location  may  be.  In  rare  cases  in  which  the  common  duct  is 
permanently  obstructed,  cholecystenterostomy  may  be  indicated. 


GENERAL  SURGERY  OF  THE  ABDOMEN  391 

It  is  probably  best  to  make  the  anastomosis  between  the  gall-bladder  and 
duodenum  where  possible,  and  between  the  gall-bladder  and  jejunum  through 
an  opening  in  the  transverse  mesocolon  where  the  duodenum  cannot  be  safely 
reached.  The  suture  method  should  be  employed  similar  to  the  one  used  in 
posterior  gastro-enterostomy. 

Surgical  treatment  of  chronic  pancreatitis.  In  chronic  pancreatitis  the 
treatment  originally  practised  and  advised  by  Mayo  Robson,  consisting  in  the 
establishment  of  perfect  drainage  through  a  cholecystostomy  opening,  seems 
to  be  still  the  best.  The  edema  of  the  common  duct  and  the  pressure  and  con- 
sequent obstruction  due  to  the  presence  of  an  enlarged  pancreas  are  thus 
relieved  and  with  this  the  pancreas  and  the  liver  are  simultaneously  reduced 
to  a  normal  size. 

The  portion  of  the  gland  that  has  been  hopelessly  destroj^ed  is,  of  course, 
permanently  lost,  but  the  remaining  portions  are  usually  sufficient  to  perform 
the  necessary  physiologic  functions  if  the  patient  is  properly  educated  in  the 
selection  of  food. 

Acute  pancreatitis.  It  is  difficult  to  make  a  differential  diagnosis  in  acute 
pancreatitis  with  any  degree  of  certainty  because  there  are  several  other 
violent  acute  conditions  which  are  so  similar  in  their  symptoms  that  they  can 
probably  never  be  positively  excluded.  The  conditions  most  likely  to  be  con- 
founded are  (1)  perforation  of  the  posterior  wall  of  the  pyloric  end  of  the 
stomach;  (2)  perforation  or  gangrene  of  the  gall-bladder  or  duodenum. 

Cases  of  severe  acute  pancreatitis  have  been  diagnosed  as  acute  intestinal 
obstruction,  renal  colic,  ectopic  gestation  and,  of  course,  appendicitis  and  gall- 
stone colic. 

Symptoms.  In  acute  pancreatitis  the  pain  is  extremely  severe  in  the  right 
upper  quadrant  of  the  abdomen.  There  is  intense  shock;  nausea  and  vomiting 
are  usually  present  and  the  patient  gives  the  impression  of  being  on  the  verge 
of  dissolution.  The  abdominal  muscles  are  tense,  although  Moynihan  found 
this  symptom  absent  in  some  of  his  cases.  There  is  usually  a  steady  rise  of 
the  pulse  from  the  onset. 

There  is  usually  a  history  pointing  to  gall-stone  colic  in  previous  milder 
attacks. 

If  a  tumor  be  felt  there  is  usually  tympanitis  on  percussion  over  this  sur- 
face because  the  gland  is  located  behind  the  duodenum. 

Cyanosis  has  been  observed  by  Opie  and  others.  Sugar  is  present  in  the 
urine  in  some  cases.  Egdahl  gives  a  careful  review  of  107  cases  in  his  study 
of  the  symptons  and  diagnosis  of  acute  pancreatitis  which  is  well  worth  the 
careful  consideration  of  the  clinician. 

Surgical  treatment  of  acute  pancreatitis.  In  mild  cases  of  acute  pancre- 
atitis surgical  treatment  is  not  indicated.  If  the  local  irritation  is  removed  by 
making  gastric  lavage  and  placing  the  patient  on  exclusive  rectal  alimenta- 
tion, so  that  nothing  passes  through  the  duodenum  for  a  time,  the  obstruction 
to  drainage  through  the  common  duct  will  soon  subside  because  of  the  disap- 
pearance of  the  local  edema,  and  then  the  conditions  will  be  favorable  for 
recovery  from  acute  pancreatitis. 

The  correctness  of  this  view  must  be  plain  to  every  one  who  has  operated 
on  a  large  number  of  patients  suffering  from  acute  gall-stone  impaction  in  the 
common  and  cystic  ducts,  at  various  periods  during  these  attacks.  If  an  opera- 
tion is  performed  during  the  attack  the  simple  drainage  of  the  gall-bladder  has 
always,  in  our  experience,  sufficed  to  relieve  the  conditions,  except  in  cases  in 
which  there  existed  at  the  same  time  a  severe  acute  cholangitis,  in  which  there 
has  been  a  mortality  of  about  30  per  cent.  A  moderate  degree  of  cholangitis 
will  subside  even  if  there  is  marked  acute  pancreatitis,  provided  the  operation 
itself  does  not  increase  the  infection. 


392  GENERAL  SURGERY  OF  THE  ABDOMEN 

The  procedure  should  be  as  simple  as  possible  and  no  rough  or  unnecessary 
handling  of  the  inllamed  tissues  should  be  employed. 

Even  in  violent  acute  cases  of  pancreatitis  a  proportion  of  patients  will 
recover  if  the  abdomen  is  quickly  opened  and  simple  drainage  introduced. 
Glass  tubes  covered  with  gauze,  split  rubber  tubes  or  cigarette  drains  may  be 
employed.  The  number  of  recoveries  depends  on  the  severity  of  the  attack  and 
the  promptness  with  which  drainage  is  supplied.  Robson  has  had  nearly  40 
per  cent,  of  recoveries.  Patients  in  whom  the  extravasation  of  pancreatic  juice 
has  caused  fat  necrosis  are  least  likely  to  recover.  AVe  have  seen  several  of 
these  that  have  recovered  without,  and  one  with,  operation  and  Mayo  reports 
similar  results. 

Unless  jaundice  is  present  it  is  best  to  limit  the  operation  to  the  location 
and  drainage  of  circumscribed  areas  of  infection  or  necrosis  of  the  pancreas, 
to  the  control  of  hemorrhage  by  means  of  fine  catgut  sutures,  and  the  free 
drainage  of  the  entire  area.  This  can  best  be  done  through  a  median  or  a  high 
right  rectus  incision.  It  is  important  to  go  over  the  gland  carefully,  but  it  is 
quite  as  important  not  to  traumatize  the  tissues  unnecessarily.  These  patients 
have  but  a  slight  margin  of  possibility  of  recovery  and  this  can  easily  be  lost 
by  unnecessary  traumatism  or  prolonged  exposure. 

If  jaundice  is  present. simple  drainage  of  the  gall-bladder,  with  removal  of 
loose  gall-stones,  is  indicated,  but  it  is  best  not  to  interfere  with  stones  im- 
pacted in  the  ducts.  AVe  lost  two  patients  needlessly  before  appreciating  the 
folly  of  doing  too  much  in  these  cases. 

Conclusions.    In  a  general  way  the  following  conclusions  seem  proper : 

1.  A  clinical  diagnosis  of  chronic  pancreatitis  is  usually  possible  before 
operation. 

2.  This  condition  is  practically  always  a  complication  of  gall-bladder  or 
gall-duct  disease,  except  when  following  metastatic  infection. 

3.  It  is  usually  curable  by  relieving  the  pathologic  condition  of  the  gall- 
bladder and  ducts. 

4.  An  operative  diagnosis  of  acute  pancreatitis  can  often  be  made. 

5.  Early  operation  greatly  improves  the  prognosis. 

6.  It  is  important  to  reduce  to  a  minimum  the  trauma  in  these  cases. 

7.  The  important  factor  in  the  treatment  consists  in  the  establishment  of 
free  drainage. 

PANCREATIC  CYSTS 

In  cysts  of  the  pancreas  resulting  from  a  total  occlusion  of  the  duct  thereof, 
usually  due  to  traumatism,  the  treatment  consists  in  making  an  incision  either 
in  the  median  line  or  through  the  rectus  abdominis  muscle.  The  tumor  will  be 
found  to  be  retro-peritoneal,  because  the  pancreas  is  a  retro-peritoneal  organ. 
The  surrounding  organs  are  tamponed  away  by  means  of  moist  aseptic  pads, 
then  the  cyst  wall  is  exposed  by  making  a  slit  in  the  peritoneum.  The  cyst  is 
then  tapped  with  a  trocar,  then  opened  and  the  remaining  fluid  sponged  away 
with  moist  pads.  Then  the  cavity  of  the  cyst  is  tamponed  lightly  with  iodo- 
form gauze  and  the  edges  of  the  wound  sutured  to  the  parietal  peritoneum  and 
transversalis  fascia  in  the  upper  angle  of  the  wound.  The  remaining  portion 
of  the  wound  is  closed  in  the  usual  manner. 

The  iodoform  gauze  is  later  gradually  removed.  If  there  is  no  secretion 
after  this  has  been  done  no  further  drainage  is  instituted,  but  if  secretion  con- 
tinues a  drainage  tube  is  inserted  when  the  tampon  has  been  removed  and  this 
is  kept  in  place  until  the  discharge  subsides,  which  usually  occurs  in  a  rela- 
tively short  time,  the  cyst  becoming  obliterated  by  the  adhesion  of  its  walls. 


GENERAL  SUEGERY  OF  THE  ABDOMEN  393 

HEMORRHOIDS 

Those  suffering  from  hemorrhoids  usually  give  a  history  of  long-continued, 
habitual  constipation.  The  patient's  occupation  is  usually  sedentary  and  the 
diet  complicated  and  unhygienic,  hemorrhoids  resulting  from  obstruction  to 
the  return  circulation  through  the  hemorrhoidal  veins.  This  obstruction  may 
be  local,  due  to  accumulations  in  the  rectum,  or  to  the  presence  of  tumors  in 
the  pelvis.  Pregnancy  is  a  common  cause,  or  it  may  be  the  result  of  obstruc- 
tion in  the  hepatic  circulation. 

Diagnosis.  There  is  a  history  of  suffering  from  a  sensation  of  fullness  in 
the  region  of  the  hemorrhoidal  veins.  This  may  be  accompanied  by  occasional 
hemorrhages,  which  give  temporary  relief  to  such  sensation.  If  the  condition 
has  existed  for  a  prolonged  time  there  is  a  protrusion  of  mucous  membrane 
containing  distended  hemorrhoidal  veins  at  each  evacuation  of  the  bowels. 
These  masses  may  become  replaced  spontaneously,  or  may  have  to  be  returned 
mechanically.  Upon  digital  examination  soft,  oval  masses  will  be  felt,  varying 
in  number  from  one  to  six  or  eight,  although  there  are  usually  not  more  than 
three  or  four.  Some  of  these  masses  are  usually  larger  than  others.  They 
sometimes  acquire  considerable  size,  rather  more  than  an  inch  in  diameter. 
In  many  there  is  a  constant  secretion  from  these  surfaces,  giving  rise,  on 
account  of  its  irritating  character,  to  an  eczema.  After  the  hemorrhoids  have 
existed  for  a  time,  the  patients  usually  complain  of  a  constant  burning  sensa- 
tion in  this  region. 

Treatment.  In  many  cases  simply  regulating  the  diet,  securing  a  regular 
free  evacuation  of  the  bowels  each  day,  and  applying  some  soothing  ointment 
or  suppository,  together  with  the  use  of  Sitz,  or  shower,  baths,  will  result  in 
relief.  If,  however,  it  has  existed  for  a  long  time  this  will  usually  not  suffice, 
and  an  operation  will  have  to  be  employed  in  order  to  secure  permanent  relief. 

The  patient  should  be  cautioned  to  eat  only  easily-digestible  food  in  very 
moderate  quantity,  to  take  a  mild  saline  laxative  every  day  for  several  days 
previous  to  undergoing  operation,  and  on  the  day  before  operation  he  should 
be  given  two  ounces  of  castor  oil,  followed  the  same  evening,  and  the  following 
morning,  with  large  flushings  of  the  colon.  In  this  manner  the  alimentary 
canal  can  be  quite  thoroughly  freed  from  material  which  might  otherwise 
irritate  the  wound  surfaces  after  the  operation. 

Operative  technique.  In  our  own  experience  the  following  operation  has 
proved  exceedingly  satisfactory  in  almost  every  instance.  The  patient  being 
anesthetized  and  placed  in  the  lithotomy  position  the  sphincter  ani  muscles  are 
very  thoroughly  dilated  by  introducing  the  thumbs  beyond  the  internal 
sphincter  and  stretching  very  slowly,  but  very  thoroughly.  The  slow  progress 
of  the  stretching  will  prevent  tearing  the  mucous  membrane  unnecessarily. 
The  stretching  should  be  continued  until  the  sphincter  remains  lax  after 
it  has  ceased.-  Each  hemorrhoid  is  then  caught  with  two  pairs  of  hemo- 
static forceps  placed  in  a  straight  line  with  the  direction  of  the  rectum,  the 
outer  one  being  from  one  to  two  centimeters,  the  second  from  two  to  four 
centimeters,  from  the  margin  of  the  anus.  A  clamp  is  then  applied  to  the 
hemorrhoid  beneath  the  attachment  of  these  forceps,  also  in  the  direction  of 
the  rectum.  If  it  is  convenient  a  clamp  which  is  protected  on  its  lower  side 
with  some  bad  conductor  of  heat,  such  as  ivory,  bone  or  rubber,  is  to  be  pre- 
ferred, otherwise  an  ordinary  pair  of  long-jawed  hemostatic  forceps  will 
serve  the  purpose  very  well.  The  surrounding  tissues  should  be  protected  by 
placing  underneath  the  forceps  a  piece  of  asbestos  cloth,  or  if  this  cannot  be 
procured,  a  piece  of  gauze  folded  half  a  dozen  times  upon  itself  and  immersed 
in  cold  water  may  be  placed  underneath  the  clamp.  A  shield  may  be  cut  out 
of  ordinary  pasteboard  and  this  may  be  immersed  in  corrosive  sublimate  solu- 


394 


GENERAL  SURGERY  OF  THE  ABDOMEN 


tion  for  a  moment  before  using.  This  is  slipped  between  the  clamp  and  the 
patient  producing  a  perfect  protection  against  burning.  The  projecting  por- 
tion of 'the  hemorrhoid  is  then  carefully  seared  by  means  of  a  cautery,  it  is 
preferable  not  to  cut  away  the  projecting  portion,  and  to  cauterize  the  small 


Clamp  and  Cautery  Operation  for  Hemorrhoids. 


Showing  forceps  a.  and  c  in  place  for  the  purpose  of  marking  hemorrhoidal  tumors  at 
beginmng  of  operation;  h  clamp  protecting  underlying  skin  by  means  of  ivory  plates  nveted 
to  lower  surface  of  jaw  plates. 

Dortion  left  beyond  the  forceps,  because  if  the  entire  hemorrhoid  is  thoroughly 
baked  with  a  cautery  not  too  hot,  there  is  never  any  danger  of  subsequent 
bleedino-  which  is  not  the  case  when  the  top  of  the  hemorrhoid  has  been  cut 
off  firsthand  the  cautery  applied  later.  Any  cautery  will  serve  the  purpose, 
but  the  one  which  we  have  found  of  the  greatest  service  consists  m  a  simple, 


GENERAL  SURGERY  OF  THE  ABDOMEN  395 

small-sized  soldering  iron,  heated  in  a  tinsmith's  heater,  in  an  ordinary  gas 
flame,  in  a  coal  stove  or  over  an  alcohol  lamp.  It  is  much  more  economical 
than  any  of  the  gasoline  or  electric  cauteries,  it  is  never  out  of  repair,  and  can 
be  easily  procured  anywhere. 

The  successive  hemorrhoids  are  then  picked  up  in  the  same  manner  and 
treated  alike. 

The  main  vessels  come  down  in  three  groups,  one  anteriorly  and  two  later- 
ally. If  these  are  caught  in  three  masses  and  cauterized,  the  remaining  hem- 
orrhoids will  usually  disappear  spontaneously.  It  is  important  in  applying 
the  clamps  always  to  leave  at  least  half  an  inch  of  normal  mucous  membrane 
in  order  to  avoid  the  production  of  stricture. 

It  is  not  wise  to  cauterize  a  hemorrhoid  exactly  in  the  median  line  in  front, 
in  a  male,  on  account  of  its  close  proximity  to  the  urethra,  as  it  frequently 
happens,  if  this  is  done,  that  an  obstruction  to  the  passage  of  urine  occurs  for 
several  days  after  the  operation,  which  may  prove  exceedingly  annoying;  and 
if  a  hemorrhoid  at  some  small  distance  to  one  side  of  the  median  line  is  caught 
the  one  which  may  exist  exactly  in  the  median  line,  and  which  may  be  larger 
than  either  of  the  others,  will  disappear  spontaneously.  It  happens  occasion- 
ally that  there  is  but  one  hemorrhoid,  and  that  this  is  just  in  the  median  line ; 
then,  of  coursej  it  will  have  to  be  clamped  in  order  to  secure  relief.  It  is  of  very 
great  importance  that  if  the  clamp  and  cautery  method  is  used  the  clamp 
should  always  be  applied  parallel  with  the  direction  of  the  rectum,  because  if 
it  is  applied  transversely  the  patient  is  almost  certain  to  suffer  from  the  forma- 
tion of  a  stricture. 

In  selecting  a  clamp  it  is  well  to  avoid  an  instrument  with  sharp  serrations, 
as  these  would  be  likely  to  injure  the  delicate  veins,  giving  rise  to  troublesome 
hemorrhage.  Even  with  a  properly  constructed  clamp  care  must  be  taken  not 
to  lacerate  the  veins. 

Ligature  method.  If  no  clamp  of  any  kind  is  available,  and  it  is  desirable 
to  relieve  a  patient  of  hemorrhoids,  this  may  be  accomplished  by  the  following 
plan,  which  we  believe  is  quite  as  satisfactory  as  the  clamp  and  cautery  method, 
but  we  have  not  performed  it  nearly  so  often,  having  become  accustomed  to  the 
other  procedure. 

The  preparatory  method  and  dilatation  are  the  same  as  in  the  operation 
just  described.  The  hemorrhoid  is  picked  up  in  the  same  manner.  It  is  then 
transfixed  with  a  needle  armed  with  double  silk  or  catgut  ligature,  about 
thirty  to  forty  centimeters  in  length.  The  needle  is  cut  away  and  the  ligature 
tied  upwards  underneath  the  second  forceps.  With  scalpel  or  scissors  the 
mucous  membrane  is  then  carefully  cut  transversely  at  the  margin  of  the  anus 
and  the  second  ligature  is  tied  in  the  groove  thus  formed.  The  projecting 
portion  of  the  hemorrhoid  is  then  cut  away,  only  a  sufficient  amount  being  left 
to  prevent  slipping  of  the  ligature.  This  method  is  applied  to  each  hemorrhoid 
in  succession  until  all  have  been  removed. 

Dressings.  The  patient  is  much  more  comfortable,  and  the  wound  will  heal 
quite  as  satisfactorily,  if  no  dressing  is  applied  after  either  the  clamp  and 
cautery  or  the  ligature  method.  For  a  considerable  time  we  habitually  applied 
some  form  of  tampon  or  drainage  to  the  rectum  after  operating  for  hem- 
orrhoids. This  was  decreased  in  amount  constantly  with  increasing  comfort 
to  the  patient,  until  at  last  we  discarded  this  form  of  dressing  entirely,  and 
latterly  for  a  large  number  of  these  cases  no  dressing  has  been  used,  except  a 
little  ordinary  pad  to  the  external  parts  held  in  place  by  a  T-bandage,  for  the 
purpose  of  absorbing  any  secretion. 

After-treatment.  The  patient  is  kept  on  liquid  diet  for  four  or  five  days. 
At  the  end  of  this  time  a  cathartic  is  given  and  before  this  causes  an  evacuation 
a  large  soap  and  water  enema  is  administered  through  a  soft  rubber  catheter. 


396  GENERAL  SURGERY  OF  THE  ABDOMEN 

This  is  repeated  after  the  cathartic  has  acted.  From  this  time  on  a  small  saline 
laxative  is  given  every  morning,  and  the  evacuation  is  followed  by  the  soap 
and  water  enema.    The  patient  is  confined  to  his  bed  for  about  a  week. 

In  unusually  severe  cases  the  excision  of  the  entire  rim  of  hemorrhoidal 
tumors  may  be  practised,  although  this  is  but  very  rarely  necessary.  Even  in 
extensive  cases  the  results,  after  the  application  of  the  clamp  and  cautery  to 
three  or  four  of  the  largest  hemorrhoids,  are  very  satisfactory,  the  others  dis- 
appearing shortly  after  the  operation.  In  case,  however,  it  seems  desirable  to 
choose  a  still  more  thorough  operation  the  following  will  bring  a  satisfactory 
outcome. 

Radical  operation.  An  incision  is  made  at  the  margin  of  the  anus  and  the 
mucous  membrane,  together  with  the  enlarged  hemorrhoidal  veins,  dissected 
out  carefully  for  a  distance  of  two  to  four  centimeters.  The  mucous  membrane 
is  then  drawn  down  from  above  and  about  eight  interrupted  catgut  stitches 
are  applied  at  regular  intervals,  reaching  through  all  the  coats  of  the  intestine 
down  to  the  mucous  membrane,  but  not  through  it,  and  through  the  subcu- 
taneous connective  tissue  at  the  margin  of  the  anus.  These  stitches  should  be 
so  applied  that  after  the  portion  of  the  rectum  containing  the  hemorrhoids  has 
been  cut  away  there  will  be  still  a  slight  projection  of  the  mucous  membrane  of 
the  rectum  beyond  the  margin  of  the  anus.  All  bleeding  points  are  caught 
during  the  operation  and  carefully  ligated  with  fine  catgut.  After  the  intestine 
has  been  sutured  in  place  in  this  manner  the  projecting  portion  is  cut  away 
and  the  mucous  membrane  of  the  intestine  sutured  accurately  to  the  skin,  the 
normal  portion  projecting  a  little  beyond  the  margin  of  the  latter.  If  the  eight 
stay  sutures  which  were  first  applied  are  carefully  placed  their  pressure  will 
control  the  hemorrhage  from  the  hemorrhoidal  veins,  so  there  will  be  no  bleed- 
ing when  the  projecting  portion  is  cut  away. 

The  treatment  after  this  operation  is  the  same  as  after  the  operations  which 
have  been  just  described. 

This  last  operation  is  very  attractive,  but  in  the  vast  majority  of  cases  it  is 
unnecessary. 

Prognosis,  It  does  not  matter  which  operation  is  chosen,  the  prognosis 
will  largely  depend  upon  the  hygienic  conditions  the  patient  provides  for  him- 
self. If  proper  food  is  taken,  if  constipation  is  avoided,  and  if  proper  exercise 
is  enjoj'^ed,  the  patient  will  remain  permanently  cured,  which  is  not  likely  if 
these  conditions  are  neglected. 

^~  FISSURE  IN  ANO 

One  of  the  most  painful  affections,  and  which  frequently  accompanies  the 
presence  of  hemorrhoids,  or  is  secondary  to  the  latter,  is  a  fissure  in  ano,  which 
is  a  small  lesion  extending  parallel  with  the  rectum,  and  consequently  at  right 
angles  with  the  sphincter  ani  muscles.  It  is  this  last  fact  which  causes  this 
condition  to  resist  treatment,  as  the  wound  constantly  gives  rise  to  spasmodic 
contractions  of  the  sphincter  ani  muscles,  and  these  in  turn  crush  the  surface 
which  is  already  sore.  The  evacuation  of  the  bowels  is  likely  to  open  the 
wound,  which  may  have  begun  to  heal  during  the  interval,  and  the  accompany- 
ing pain  gives  rise  to  spasmodic  contraction  of  the  sphincter  muscles ;  conse- 
quently the  patient  suffers  severely  for  some  time  after  the  bowels  have  been 
evacuated.  The  application  of  remedies  is  of  very  little  benefit,  for  the  rea- 
sons just  mentioned.  Unless  the  condition  is  but  very  slight  an  operation  must 
usually  be  resorted  to  before  the  patient  can  be  properly  and  completely 
relieved. 

Technique.  The  operation  in  moderate  cases  consists  simply  in  thoroughly 
dilating  the  sphincter  ani  muscles  so  that  the  wound  may  remain  at  rest  for  a 


GENERAL  SURGERY  OF  THE  ABDOMEN  397 

few  days.  At  the  end  of  this  time  it  will  have  healed  spontaneously.  If,  how- 
ever, the  fissure  has  existed  for  a  number  of  months,  or  years,  the  amount  of 
cicatricial  tissue  formed  along  its  course  may  be  considerable,  and  then  the 
simple  operation  of  stretching  the  sphincter  ani  muscles  may  no  longer  suffice 
to  give  relief.  In  such  cases  the  muscles  should  be  stretched  very  thoroughly, 
and  then  the  cicatricial  tissue  excised  and  the  mucous  membrane  brought  down 
from  above  and  attached  to  the  wound  at  the  margin  of  the  anus  with  a  few 
fine  catgut  sutures.  This  simple  method  has,  in  our  experience,  resulted  in  the 
relief  of  even  very  severe  cases  which  had  existed  for  a  long  time. 
The  after-treatment  is  the  same  as  in  operation  for  hemorrhoids. 

FISTULA  IN  ANO 

It  is  but  rarely  that  one  suffering  from  fistula  in  ano  comes  under  the  care 
of  a  surgeon  during  the  early  part  of  his  disease.  He  has  usually  suffered  for 
months,  or  years,  and  has  made  use  of  various  local  remedies  without  benefit. 

History.  The  patient  gives  a  history  of  having  suffered  from  an  acute 
infection  in  the  ischio-rectal  fossa,  which  resulted  in  an  abscess,  variable  in  size, 
opening  spontaneously  or  by  an  incision.  Before  the  occurrence  of  this  infec- 
tion there  is  generally  a  history  of  hemorrhoids.  There  has  usually  been  a 
discharge  of  pus  from  the  opening  for  a  considerable  time,  during  which  the 
patient  is  fairly  free  from  pain.  Then  the  opening  would  close  and  there 
would  be  a  reaccumulation  of  pus  within  the  abscess,  again  provoking  much 
suffering.  These  events  may  have  existed  for  a  greater  or  less  extent  of  time, 
and  there  may  have  been  a  variable  number  of  reaccumulations  of  pus.  There 
may  be  one  or  a  number  of  external  openings.  Quite  a  considerable  proportion 
of  these  cases  give  a  history  of  cough,  and  upon  examination  some  evidence  of 
pulmonary  tuberculosis  may  be  established. 

The  usual  practice  of  introducing  a  probe  into  one  of  these  fistulae  is,  we 
believe,  to  be  condemned,  because  it  gives  rise  to  an  amount  of  pain,  it  may 
produce  a  new  infection,  and  it  does  not  afford  the  surgeon  any  information 
which  he  cannot  obtain  by  simply  looking  at  the  external  surface,  and  by  mak- 
ing a  digital  examination. 

Technique.  The  treatment  should  invariably  be  surgical,  although  long- 
continued  applications,  curettements  and  irrigations  may,  in  very  rare  cases, 
result  in  a  cure  of  the  rectal  fistula ;  still  these  instances  are  so  uncommon  that 
it  is  much  better  to  invariably  proceed  to  the  radical  surgical  treatment  as  soon 
as  the  consent  of  the  patient  can  be  obtained. 

The  preparatory  treatment  should  be  the  same  as  that  described  for  hem- 
orrhoid operation.  The  patient  is  anesthetized  and  the  sphincter  ani  muscles 
dilated.  Then  a  grooved  director  is  inserted  into  the  fistula  from  without  and 
the  finger  within  the  rectum  feels  for  a  little  projection  in  the  form  of  a  granu- 
lation, readily  found  in  quite  a  large  proportion.  By  carefully  manipulating 
the  grooved  director  it  will  find  its  way  along  the  fistula  to  a  point  opposite  this 
granulation,  through  which  it  can  be  pushed  into  the  rectum.  Then  an  incision 
is  made  directly  through  all  of  the  tissues  between  the  grooved  director  and 
the  rectum.  Sharp  retractors  are  placed  in  the  edges  of  the  wound  and  the 
granulations  carefully  curetted  away.  If  the  sugeon  looks  for  prolongations 
of  the  fistula,  even  these,  too,  in  case  they  exist,  end  in  a  little  granulation 
tissue  projecting  into  the  sinus  which  has  been  curetted.  By  looking  for  this 
little  granulation  one  can  feel  all  the  various  sinuses,  and  by  laying  them  open 
freely  and  curetting  away  the  granulation  tissue,  obtain  a  perfectly  clean 
wound.  If  the  fistula  have  burrowed  through  the  tissues  beyond  the  sphincter 
ani  muscles  in  various  places  the  latter  should  not  be  severed  except  at  the 
point  of  the  first  incision,  for  fear  of  having  the  patient  lose  control  over  the 


398 


GENERAL  SURGERY  OF  THE  ABDOMEN 


action  of  the  bowels  and  the  passage  of  gas.  In  case  the  fistula  has  existed  for 
a  long  time  the  cicatricial  tissue  formed  should  be  dissected  away  with  a  sharp 
scalpel,  in  order  to  leave  the  surface  perfectly  free  and  to  have  all  portions  of 
the  wound  as  clean-cut  surfaces.  If  all  of  the  infected  tissue  has  been  removed, 
the  course  to  be  followed  may  consist  in  tamponing  the  raw  surface  with  iodo- 
form gauze,  to  be  left  in  place  for  a  number  of  days,  and  then  replaced  daily 
after  evacuation  of  the  bowels,  or  the  surface  may  be  closed  by  suturing.  The 
latter  method  should  only  be  chosen  when  the  surgeon  is  absolutely  certain 
that  all  portions  of  the  infected  tissue  have  been  thoroughly  removed.  Then 
deep,  silkworm  gut  sutures  may  be  inserted  so  they  are  buried  throughout 
their  entire  extent,  entering  the  tissues  at  a  point  half  an  inch  from  the  edge  of 
the  original  wound,  passing  entirely  around  the  area  of  the  wound  and  issuing 
on  the  opposite  side  half  an  inch  from  the  edge  of  the  original  incision.  The 
mucous  membrane  of  the  rectum  may  be  sutured  separately  with  a  row  of  cat- 
gut sutures,  the  silkworm  sutures  remaining  untied  in  the  meantime.  If  the 
sphincter  ani  muscles  have  been  cut  a  few  catgut  sutures  may  be  passed 


1.  Bi.iND  External  Fistula.     2.  Complete  Fistula.     3.  Blind  Internal  Fistula. 

through  them  and  tied  separately.  Then  the  deep  silk-worm  gut  sutures  are 
tied  over  all  and  a  few  coaptation  stitches  applied  to  the  skin.  This  method 
will  succeed  in  healing  most  of  the  simple  fistulae  within  ten  days  or  two 
weeks ;  at  the  end  of  which  time  the  deep  silk-w^orm  gut  sutures  are  removed. 
After-treatment.  The  after-treatment  is  the  same  as  in  operation  for  hem- 
orrhoids. If,  however,  the  wound  has  not  been  closed  with  sutures  an  enema 
should  be  given  after  each  evacuation  of  the  bowels,  and  then  the  iodoform 
gauze  tampon  again  applied  to  the  wound,  in  order  to  compel  the  latter  to  heal 
from  the  bottom. 


PROLAPSE  OF  THE  RECTUM 

This  occurs  more  frequently  in  childhood  than  during  any  other  period. 
It  is  usually  the  result  of  straining  due  to  constipation,  or  on  account  of 
phimosis  in  young  children,  or  because  of  the  presence  of  a  fissure,  giving 
rise  to  tenesmus.  The  mucous  membrane  of  the  rectum  usually  prolapses 
during  the  evacuation  of  the  bowel  and  it  becomes  difficult  and  painful  to 
replace  it. 

Technique.  If  one  of  the  causes  mentioned  still  exists,  it  should  be  relieved 
and  the  condition  treated  in  a  non-surgical  way  at  first.  The  patient  should  be 
placed  in  the  inverted  position  and  gentle  pressure  made  upon  the  prolapsed 


GENERAL  SURGERY  OF  THE  ABDOMEN  399 

portion,  and  a  suppository  composed  of  cocoa  butter,  some  mild  antiseptic 
substance,  and  some  astringent  substance,  should  be  inserted  into  the  bowel. 
The  lower  end  of  the  child's  bed  should  be  elevated  so  as  to  add  the  benefit 
of  gravitation  to  the  treatment.  If  this  form  of  treatment  does  not  succeed 
in  relieving  the  child,  he  should  be  anesthetized,  the  sphincter  ani  muscles 
very  gently  dilated,  and  then  the  treatment  with  clamp  and  cautery  described 
under  the  head  of  hemorrhoids  employed,  with  the  exception  that  only  a  very 
small  depth  of  tissue  should  be  caught  by  the  clamp,  and  also  that  the  eschar 
extend  a  distance  of  three  or  four  centimeters  along  the  lower  end  of  the 
bowel.  Three,  or  at  least  four,  longitudinal  eschars  will  almost  always  suffice 
to  relieve  a  prolapse  in  children.  Of  course,  the  same  care  should  be  exercised 
to  have  the  eschars  extend  parallel  with  the  bowel,  in  connection  with  the 
clamp  and  cautery  operation  for  hemorrhoids. 

In  severe  forms.  In  the  adult  prolapse  frequently  follows  the  long-con- 
tinued existence  of  hemorrhoids,  and  usually  the  relief  of  the  latter  will 
result  in  the  relief  of  the  prolapse.  In  rare  instances  it  happens,  however, 
that  neither  of  the  operations  described  for  the  relief  of  hemorrhoids  could 
promise  any  relief  in  this  condition  because  the  entire  wall  of  the  intestine 
may  have  prolapsed  through  the  anus  for  a  distance  of  a  number  of  inches. 
In  this  event  the  prolapse  should  be  reduced,  after  the  preparations  described 
in  connection  with  hemorrhoid  operations  have  been  carried  out.  The  patient 
should  be  placed  in  bed,  with  the  foot  of  the  bed  elevated  from  six  to  ten 
inches.  This  position  is  kept  for  a  variable  period,  depending  upon  the  sever- 
ity of  the  prolapse — from  one  or  two  days  to  as  many  weeks — in  order  to 
disperse  the  edema  which  may  exist  in  the  intestine.  Then  an  abdominal 
section  is  made  through  the  median  line  and  the  lower  end  of  the  sigmoid 
flexure  is  found  and  carried  to  the  left  side  of  the  abdominal  cavity  and 
stitched  by  means  of  a  considerable  number  of  fine  silk  sutures  directly  to 
the  abdominal  wall  a  little  in  front  of  its  normal  location.  In  this  manner  the 
entire  rectum  and  the  lower  end  of  the  sigmoid  flexure  will  be  carried  upwards 
sufficiently  to  prevent  recurrence  of  the  prolapse.  The  sphincter  ani  muscles 
should  be  very  thoroughly  stretched  so  as  to  prevent  any  obstruction  to  the 
passage  of  gas  and  feces  until  the  intestine  has  become  firmly  united  with  the 
parietal  peritoneum. 

If  the  sigmoid  is  drawn  upwards,  when  the  abdomen  is  opened  with  the 
patient  lying  in  the  Trendelenburg  position,  the  prolapsing  peritoneal  pouch 
can  be  seen  and  obliterated  with  interrupted  silk  sutures,  which  will  give  the 
rectum  a  very  substantial  support. 

It  is  important  that  a  non-absorbable  suture  be  used,  because  if  the  intes- 
tine is  sutured  with  ordinary  catgut  the  adhesions  will  be  likely  to  absorb 
and  the  patient  suffer  from  a  recurrence,  while  if  silk  or  chromicized  catgut 
is  employed  this  cannot  occur.  The  bowels  should  be  carefully  regulated  after 
this  operation,  so  that  there  never  is  too  great  an  accumulation  in  the  large 
intestine. 

All  other  causes  of  intra-abdominal  pressure  should  also  be  overcome.  If 
there  is  an  obstruction  to  the  passage  of  urine  due  to  the  presence  of  a  stricture 
or  enlargement  of  the  prostate  gland,  it  should  be  relieved.  If  the  patient  is 
suffering  from  a  great  accumulation  of  fat  in  the  omentum,  mesentery  and 
abdominal  walls,  it  should  be  relieved  by  proper  diet  and  exercise.  If  all  of 
these  precautions  are  carried  out  a  recurrence  is  not  likely. 

CARCINOMA  OF  THE  RECTUM 

Patients  suffering  from  carcinoma  of  the  rectum  usually  give  a  history  of 
long-continued  irregularity  in  the  evacuation  of  the  bowels.     At  first  there 


400  GENERAL  SURGERY  OF  THE  ABDOMEN 

is  usually  long-continued  constipation;  then  this  is  interrupted  by  occasional 
attacks  of  diarrhea ;  then  a  history  of  the  evacuation  of  ribbon-like  forma- 
tions of  feces,  indicating  some  constriction  in  the  rectum,  and  later  on  there 
is  usually  complete  temporary  obstruction  which  may  exist  for  only  a  short 
time  at  first  and  may  recur  at  various  intervals,  or  the  patient  may  come 
under  the  observation  of  the  surgeon  during  the  first  one  of  these  attacks  of 
obstruction.  In  most  cases  there  is  a  passage  of  thick  mucus,  either  with  the 
bowel  evacuation  or  during  the  interval  between  evacuations.  In  many  there 
is  also  a  slight  amount  of  hemorrhage,  and  very  rarely  one  of  these  patients 
suffers  from  a  severe  hemorrhage  from  the  rectum. 

Upon  examination  a  hard,  nodular  mass  is  felt  in  the  rectum,  usually  w4th 
a  small  central  opening,  or  the  mass  may  be  upon  one  side  of  the  rectum  and 
on  the  other  the  mucous  membrane  may  be  normal.  The  sensation  to  the 
touch  of  a  carcinoma  of  the  rectum  is  so  characteristic  that  if  a  surgeon  has 
once  experienced  it  he  will  have  no  difficulty  thereafter  in  its  recognition. 
It  differs  from  the  feel  of  a  stricture  because  of  the  nodular  character,  and 
because  of  the  tumor-like  projection  of  the  mass,  while  a  cicatricial  stricture 
simply  presents  the  sensation  of  a  narrowing  of  the  canal.  It  differs  from  a 
tubercular  stricture  from  the  fact  that  although  the  latter  also  is  nodular  in 
character  it  does  not  give  the  impression  of  a  tumor-like  projection. 

Technique.  If  the  carcinoma  is  in  the  lowest  portion  of  the  rectum,  does 
not  extend  above  the  cul-de-sac  of  Douglas,  and  is  movable,  the  treatment 
should  consist  in  the  excision  of  the  entire  mass,  together  with  the  surrounding 
tissues  to  as  great  an  extent  as  possible.  The  incision  through  the  skin  should 
be  free,  should  pass  up  behind  to  the  lower  edge  of  the  sacrum,  should  include 
the  coccyx,  and  the  entire  mass  should  be  loosened  from  its  attachment  in 
one  piece,  so  as  to  avoid  the  implantation  of  carcinomatous  tissue  during  the 
operation.  The  rectum  should  be  freed  for  a  distance  of  at  least  two  inches 
beyond  the  upper  margin  of  the  carcinoma,  two  pairs  of  strong  forceps  should 
be  applied  to  the  bowel  at  this  point,  and  the  latter  severed  between  these 
forceps  and  the  tumor  thus  removed.  The  bleeding  vessels  should  be  caught 
during  the  operation,  so  that  the  loss  of  blood  will  be  reduced  to  a  minimum, 
and  from  time  to  time  all  of  these  vessels  thus  caught  should  be  ligated  so  as 
to  leave  the  field  of  operation  as  free  from  obstruction,  on  account  of  the  pres- 
ence of  hemostatic  forceps,  as  possible.  The  upper  segment  of  the  intestine 
should  then  be  freed  sufficiently  so  that  it  can  be  brought  into  the  upper  angle 
of  the  wound  and  carefully  sutured  to  the  skin. 

We  have  never  encountered  a  carcinoma  of  the  rectum  in  which  it  seemed 
safe  to  preserve  the  sphincter  ani  muscles.  In  a  few  cases  in  which  we  have 
attempted  to  remove  the  malignant  growth  and  to  attach  the  upper  segment 
of  the  intestine  to  the  lower  segment,  thus  preserving  the  sphincter  ani  muscles, 
there  has  been  a  recurrence,  but  in  the  vast  majority  the  fact  that  a  recur- 
rence would  follow  was  so  plain  at  the  time  of  the  operation  that  the  preser- 
vation of  the  sphincter  ani  muscles  was  not  undertaken. 

If  carcinoma  of  the  rectum  is  so  far  advanced  that  a  rapid  recurrence 
would  be  inevitable  in  case  of  its  excision,  which  can  usually  be  predicted 
when  the  tumor  is  removed,  then  we  believe  it  is  much  wiser  simply  to  do 
an  inguinal  colostomy,  already  described  earlier  in  this  section. 

If  the  carcinoma  is  in  the  upper  portion  of  the  rectum,  or  in  the  low^er 
portion  of  the  sigmoid  flexure,  then  one  of  the  operations  previously  described 
in  this  section  should  be  done.  In  the  female  it  often  occurs  that  the  carcinoma 
is  upon  the  anterior  surface  of  the  rectal  wall  and  has  attacked  the  recto- 
vaginal septum:  then  the  posterior  vaginal  wall  should  be  removed,  together 
with  the  entire  rectum,  after  the  method  above  described. 

The  after-treatment  is  the  same  as  in  operations  for  hemorrhoids,  with 


GENERAL  SURGERY  OF  THE  ABDOMEN  401 

the  exception  that  the  wound  should  be  dressed  daily  in  order  to  prevent  its 
infection. 

Prognosis.  TVTiere  the  carcinoma  has  not  perforated  any  portion  of  the 
intestine,  the  prognosis  is  relatively  good,  provided  the  amount  of  tissue  re- 
moved is  quite  as  extensive  as  though  the  case  were  advanced  in  its  develop- 
ment. In  advanced  cases  the  prognosis  is  not  good,  without  regard  to  the 
operation  chosen.  In  our  experience  the  cases  in  which  permanent  inguinal 
colostomy  was  made  prior  to  the  excision  of  the  carcinoma  have  lived  longer 
than  those  in  which  the  feces  were  permitted  to  pass  through  the  rectum  after 
the  excision  of  the  growth. 

If  it  seems  possible  to  secure  a  radical  removal  of  the  carcinoma  by  includ- 
ing a  portion  of  the  vaginal  wall  the  following  steps  should  be  taken  in  the 
operation.  Long,  narrow  retractors  are  introduced  to  each  side  into  the 
vagina  in  order  to  expose  its  posterior  wall  freely,  then  an  elliptical  incision 
is  made  to  include  the  entire  posterior  vaginal  wall.  The  bleeding  vessels 
are  carefully  caught  and  ligated  and  the  incision  carried  backward  on  each 
side  and  around  the  anus  a  distance  of  at  least  4  cm.  from  the  anal  orifice. 
The  two  incisions  will  meet  opposite  the  tip  of  the  coccyx.  From  this  point 
a  median  incision  is  carried  upward  to  a  point  3  cm.  above  the  lower  end  of 
the  sacrum.  At  this  point  the  wound  is  held  open  by  means  of  retractors  and 
the  coccyx  separated  from  its  attachment  to  the  sacrum  by  means  of  a  chisel. 
This  bone  is  left  attached  to  the  rectum,  with  which  it  is  removed.  It  is  not 
uncommon  to  find  just  in  front  of  the  coccyx,  or  in  front  of  the  sacrum,  one 
or  more  infected  lymph  glands,  and  great  care  should  be  exercised  in  remov- 
ing the  tissues  at  this  point.  The  entire  tumor,  together  with  the  surrounding 
tissues,  is  now  dissected  out,  care  being  taken  to  grasp  the  bleeding  vessels  as 
soon  as  they  are  severed,  especially  the  branches  of  the  inferior  pudic  artery 
and  the  hemorrhoidal  vein,  in  order  to  reduce  the  shock  from  hemorrhage 
to  a  minimum.  This  leaves  the  entire  mass  dissected  out  and  only  attached 
above  to  the  healthy  intestine. 

The  intestine  is  then  at  once  grasped  by  two  pairs  of  hemostatic  forceps 
at  least  4  cm.  above  the  upper  margin  of  the  tumor.  By  cutting  the  intes- 
tine between  these  the  tumor  can  be  removed  without  danger  of  soiling  the 
wound.  The  upper  segment  is  now  carefully  loosened  so  it  can  be  brought 
down  without  tension.  It  is  important  to  clamp  the  tissues,  in  doing  this, 
before  they  are  severed,  with  the  hemostatic  forceps  in  order  to  prevent 
dangerous  hemorrhage.  These  tissues  are  carefully  ligated  after  the  intes- 
tine has  been  thoroughly  loosened.  Then  the  intestine  is  brought  down  and 
sutured  to  the  posterior  margin  of  the  incision.  It'  is  important  to  carry  the 
intestine  at  least  3  cm.  beyond  the  margin  of  the  skin  because  if  this  precau- 
tion is  not  taken  it  is  almost  certain  to  retract,  and  if  it  retracts  within  the 
margin  of  the  skin  a  stricture  is  sure  to  occur.  Here,  as  in  all  cases  in  which 
tubular  stricture  is  brought  to  the  surface,  it  is  best  to  apply  a  number  of 
sutures  several  cm.  back  from  the  outer  surface  for  the  purpose  of  attaching 
the  intestine  to  the  wound  surface,  through  which  it  is  carried.  Retraction 
of  the  intestine  is  much  less  likely  to  occur  if  this  precaution  is  taken.  Aside 
from  this  it  is  well  to  apply  at  least  four  sutures  2  cm.  from  the  margin  of  the 
intestine  to  the  skin,  and  the  same  number  directly  between  the  margin  and 
the  skin. 

THE  COMBINED  ABDOMINAL  AND  PERINEAL  METHOD  OF  REMOV- 
ING CARCINOMA  OF  THE  RECTUM 

"Where  the  carcinoma  of  the  rectum  extends  upward  too  far  to  be  com- 
pletely removable  from  below,  it  is  well  to  begin  the  operation  after  the  method 


402  GENERAL  SURGERY  OF  THE  ABDOMEN 

just  described,  loosening  the  rectum  from  below  together  with  the  tumor,  re- 
moving the  lymph  nodes  and  fat  and  thoroughly  controlling  the  hemorrhage. 
Then  the  entire  space  should  be  thoroughly  tamponed  with  gauze  and  covered 
with  sterile  towels. 

The  patient  is  then  placed  in  the  exaggerated  Trendelenburg  position  and 
a  large  median  abdominal  incision  made  extending  from  the  pubis  to  the 
umbilicus.  The  sigmoid  is  brought  into  the  wound  and  the  point  determined 
sufficiently  far  above  the  tumor  to  prevent  recurrence.  Two  clamps  are 
applied  at  this  point  and  the  sigmoid  cut  between  them. 

The  upper  end  is  covered  with  gauze  and  the  lower  segment  carefully  dis- 
sected out  by  applying  forceps  successively  to  the  vessels  entering  the 
intestine. 

The  dissection  is  carried  on  until  the  portions  of  the  sigmoid  and  rec- 
tum have  been  completely  dissected  out,  when  this  will  be  removed  together 
with  the  tumor.  All  of  the  fat  and  the  lymph  nodes  are  then  dissected  out 
with  gauze  dissection,  then  all  of  the  vessels  are  ligated,  the  wound  is 
drained  downward  with  cigarette  and  gauze  drainage  and  the  entire  surface 
covered  with  peritoneum. 

The  upper  segment  of  the  sigmoid  is  then  passed  through  the  abdominal 
wall,  according  to  the  method  described  under  inguinal  colostomy,  and  the 
abdominal  wall  is  closed. 

If  the  tumor  is  fairly  circumscribed,  the  prognosis  is  good  after  this 
operation. 

TUMORS  OF  THE  ABDOMINAL  WALL 

Lipoma.  Fatty  tumors  are  occasionally  found  in  the  abdominal  walls  and 
can  be  removed  without  danger  by  simply  making  an  incision  down  to  the 
growth,  enucleating  it,  and  closing  the  wound  in  the  skin. 

Fibro-sarcoma.  Fibro-sarcomata  frequently  occur  in  the  abdominal  walls, 
taking  their  origin  from  any  one  of  the  various  fascias ;  hence  their  name, 
desmoids.  These  tumors  usually  follow  severe  straining  during  labor  and  most 
commonly  occupy  the  lower  end  of  the  abdominal  muscles. 

They  should  \>&  removed  freely,  a  considerable  amount  of  the  surrounding 
tissue  being  sacrificed.  This  usually  involves  one  or  more  of  the  important 
muscles  of  the  abdominal  wall  which  must  be  replaced  by  a  plastic  operation 
consisting  in  the  splitting  of  other  portions  of  the  abdominal  wall  and  over- 
lapping. Fortunately  these  tumors  are  relatively  not  very  malignant,  and  a 
number  have  been  permanently  cured  by  removal.  It  is  usually  well  for 
patients  to  wear  some  form  of  abdominal  supporter  after  recovering  from  this 
operation. 

ABSCESSES  IN  THE  ABDOMINAL  WALL 

Abscesses  in  the  abdominal  wall  sometimes  follow  traumatism,  but  more 
frequently  result  from  an  infection  within  the  peritoneal  cavity  which  has 
perforated  a  portion  of  the  abdominal  wall,  from  infections  of  the  ribs  which 
have  burrowed  downward,  from  empyemata  of  the  chest  which  have  bur- 
rowed downward,  or  from  tubercular  abscesses  of  the  spine  which  have  fol- 
lowed some  portion  of  the  transversalis  fascia.  The  intra-peritoneal  origin 
of  these  abscesses  is  most  commonly  the  vermiform  appendix,  Fallopian  tube, 
gall-bladder,  stomach,  kidney,  or  urinary  bladder.  Foreign  bodies,  such  as 
needles,  nails  or  sharp  bones,  may  penetrate  any  portions  of  the  alimentary 
canal  and  through  adhesions  of  these  to  the  abdominal  wall,  penetrate  the 
latter  and  give  rise  to  abscesses. 


GENEEAL  SURGERY  OF  THE  ABDOMEN  403 

Treatment.  If  the  abscess  is  not  tubercular  in  character  it  is  best  to  lay  it 
widely  open,  curette  away  all  granulation  tissues  carefully,  and  by  looking 
for  small  areas  in  which  granulation  tissue  persists,  one  can  usually  follow  the 
abscess  to  the  point  from  which  the  infection  originated.  If  this  can  be  done 
and  the  cause  removed  with  safety,  it  is  well.  If  the  origin  of  the  infection 
cannot  be  found  it  is  best  to  tampon  the  abscess  cavity  widely  open  and  at 
the  future  dressing  look  for  the  source  of  infection,  which  can  be  determined 
from  the  fact  that  at  some  point  there  will  be  a  new  accumulation  of  pus. 
Often  during  the  original  operation  the  source  of  infection  may  be  deter- 
mined by  making  pressure  upon  the  surrounding  portions  of  the  abdominal 
wall  and  watching  for  some  point  from  which  pus  shows  upon  such  pressure. 

Thoroughness  in  exploration  is  the  foundation  of  success  in  operation  for 
the  relief  of  this  condition.  If  it  does  not  seem  safe  to  follow  the  infection 
to  its  point  of  origin  at  the  first  operation,  it  is  often  best  to  tampon  the 
abscess  cavity  and  later  approach  the  condition  from  the  abdominal  cavity 
through  a  new  incision,  the  location  of  infection  having  been  determined  by 
the  primary  operation. 

INFECTION  OF  THE  UMBILICUS 

Frequently  in  infants,  and  occasionally  in  the  adult,  infection  of  the 
umbilicus  occurs,  which  may  result  simply  in  a  slight  superficial  ulcer  char- 
acterized by  a  tendency  to  remain  open,  or  it  may  be  deep-seated  forming 
an  abscess  of  the  abdominal  wall  which  may  vary  in  depth,  occasionally  ex- 
tending down  to  the  peritoneum. 

Treatment.  In  superficial  infections  simple  disinfection,  the  application 
of  antiseptic  dressings,  and  keeping  the  surface  clean,  will  result  in  healing. 
In  deep-seated  infections,  it  is  important  to  curette  away  all  of  the  infected 
tissue  down  to  the  deepest  portion  of  the  infected  part,  to  disinfect  the  sur- 
face and  tampon  and  permit  healing  to  take  place  from  the  bottom.  In  either 
case  the  patient  should  be  kept  at  rest. 

Occasionally  such  an  infection  depends  upon  a  remnant  of  the  omphalo- 
mesenteric duct  which  should  have  been  obliterated  before  the  birth  of  the 
child.  In  such  cases  the  mucous  membrane  lining  this  embryonic  structure 
must  be  entirely  removed  in  order  to  secure  a  permanent  cure,  because  any 
remnant  will  be  sure  to  be  the  cause  of  a  new  abscess  as  soon  as  the  tissues 
have  healed  over  this  area. 

In  many  of  these  the  duct  is  continuous  with  the  lumen  of  the  small  intes- 
tine. Then  it  is  necessary  to  perform  an  abdominal  section,  excise  the  entire 
umbilicus,  determine  its  point  of  attachment  to  the  intestine  and  treat  this 
attachment  precisely  after  the  manner  of  removing  the  appendix  from  the 
cecum,  especial  care  being  taken  not  to  narrow  the  lumen  of  the  small  intes- 
tine at  the  point  of  removal  of  this  remnant  of  the  duct. 


PART  VI 

SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


SURGERY  OF  THE  ESOPHAGUS 

Surgery  of  the  esophagus  in  comparison  with  surgery  of  the  rest  of  the 
gastro-intestinal  tract  is  limited  and  probably  will  always  remain  so  on  ac- 
count of  the  nature  and  position  of  the  part. 

In  many  conditions  the  treatment  is  of  a  palliative  character.  The  distress 
from  interference  with  the  function  of  the  esophagus  is  so  great  that  these 
palliative  measures  seem  worth  while. 

Methods  of  examination.  The  most  common  method  is  the  passing  of 
bougies.  In  sounding  the  esophagus  it  is  important  to  remember  that  under 
normal  conditions  the  canal  possesses  four  constrictions.  It  is  also  im- 
portant to  know  the  total  length  of  the  tract  and  the  distance  of  its  most 
important  portion  from  the  teeth.  The  esophagus  is  ten  inches  in  length.  It 
begins  six  inches  from  the  incisor  teeth  and  passes  through  the  diaphragm  six- 
teen inches  from  the  teeth.  It  is  crossed  by  the  arch  of  the  aorta  ten  inches 
from  the  teeth. 

The  examination  with  a  bougie  should  be  conducted  very  carefully  and 
slowly,  for  in  this  way  only  is  it  possible  to  follow  the  course  of  the  tube  with- 
out injury,  especially  when  it  is  in  a  diseased  condition. 

Two  kinds  of  bougies  may  be  used  for  sounding  the  esophagus,  the  English 
bougies  or  the  olive-tipped  bougies.  The  former  are  constructed  of  a  woven 
material,  impregnated  with  a  gummy  substance,  and  may  be  softened  or 
hardened  by  placing  them  in  warm  or  cold  water,  respectively.  In  this  man- 
ner they  may  be  bent  into  any  desired  shape.  The  olive-pointed  bougies  con- 
sist of  a  flexible  hard  rubber  stalf,  on  the  point  of  which  is  placed  an  olive- 
shaped  tip  of  hard  rubber  or  ivory. 

When  a  stricture  is  present  it  is  easier  to  determine  its  location  by  means 
of  the  olive-tipped  than  by  the  English  bougie. 

Before  sounding  an  esophagus,  artificial  teeth  should  be  removed  and  the 
patient  examined  for 'aneurism  of  the  aorta.  The  passing  of  bougies  in  cases 
of  aortic  aneurism  has  been  known  to  cause  death  from  hemorrhage. 

Patients  who  are  being  examined  for  the  first  time  are  apt  to  gag,  making 
the  procedure  very  unpleasant.  This  may  be  overcome  to  a  great  extent  by 
first  spraying  the  pharynx  with  a  four  per  cent,  solution  of  cocaine,  allowing 
the  patient  to  swallow  a  little  of  same,  then  waiting  five  minutes  before  pass- 
ing the  sounds.  The  bougies  are  passed  with  the  patient  in  a  sitting  posture, 
with  the  head  erect  or  bent  a  little  forward;  then  the  operator  places  the 
index  finger  of  his  left  hand  on  the  base  of  the  tongue,  pressing  downward 
and  forward,  while  the  bougie  is  passed  by  the  right  hand  along  the  posterior 
wall  of  the  pharynx  to  the  beginning  of  the  esophagus.  The  patient  is  now 
told  to  swallow  and  the  sound  will  pass  on  into  the  esophagus. 

A  half-inch  bougie  should  easily  pass  through  every  portion  of  the  esoph- 
agus. Its  failure  so  to  pass  is  a  sign  of  stricture.  A  three-fourths-inch  bougie 
is  as  large  as  should  ever  be  used  in  dilating  a  stricture. 

405 


406      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Occasionally  in  passing  the  bougie  one  meets  with  an  apparent  obstruction. 
In  these  eases  it  is  sufficient  under  normal  conditions  to  withdraw  the  bougie 
a  short  distance  and  then  advance  it  again,  or  the  obstruction  may  be  over- 
come by  asking  the  patient  to  swallow  or  to  bend  the  head  a  little  forward. 

Esophagoscopy.  Esophagoscopy  cannot  be  considered  an  important  aid  in 
diagnosis.  Little  is  to  be  determined  by  this  means  that  cannot  be  ascer- 
tained by  the  more  simple  methods  of  examination.  The  simplest  and  safest 
form  of  esophagoscopy  is  by  the  straight  tube,  the  light  being  thrown  into  this 
by  either  a  Leiter  panelectroscope  or  a  Casper  electroscope.  Numerous  de- 
vices for  esophagoscopy  have  been  invented  during  the  past  few  years,  but 
not  much  evidence  of  value  has  accumulated  from  their  use.  Esophagoscopy 
should  only  be  attempted  by  those  who  have  had  special  training  along  this 
line  of  work. 

Radioscopy.  Radioscopy  is  frequently  a  valuable  aid  in  the  diagnosis  of 
esophageal  lesions,  especially  in  the  location  of  foreign  bodies.  It  may  also 
be  considered  in  connection  with  the  diagnosis  of  strictures,  dilatation  and 
diverticula. 

A  rather  definite  outline  of  the  esophagus  may  be  obtained  by  an  X-ray 
photograph  by  administering  a  large  quantity  of  bismuth,  mixed  with  some 
starchy  food,  just  before  the  picture  is  taken. 

Percussion.  Percussion  is  of  minor  importance  in  the  diagnosis  of  lesions 
of  the  esophagus.  In  diverticulum  in  the  neck,  if  the  latter  is  filled  with 
ffas,  percussion  will  give  a  tj'mpanitic  note ;  if  filled  with  food,  a  dull  note. 
Occasionallj'  in  the  presence  of  a  growth  in  the  esophagus  one  is  able  to 
determine  a  dull  area  corresponding  to  the  location  of  the  tumor. 

INFLAMMATORY  PROCESSES  OF  THE  ESOPHAGUS 

Acute  catarrhal  inflammation  of  the  esophagus  may  result  from  the  irrita- 
tion caused  by  foreign  bodies,  from  a  mild  scalding,  or  from  swallowing  some 
chemical  causing  an  irritation  but  not  strong  enough  to  cauterize.  It  is 
characterized  by  the  secretion  of  mucoid  material.  Where  the  inflammation 
is  more  severe,  it  may  result  in  superficial  erosion  or  ulcers,  but  these  usually 
heal  without  any  serious  consequences. 

Chronic  catarrhal  inflammation  of  the  esophagus  occurs  in  chronic  al- 
coholics, also  in  cases  of  stenosis  of  the  esophagus  from  various  causes,  and 
from  the  accumulation  of  food  in  a  dilated  portion  above  a  stricture.  These 
eases  usually  recover  without  any  complications  by  relieving  the  cause  of  the 
inflammation. 

TOXIC  ESOPHAGITIS 

Toxic  or  corrosive  esophagitis  occurs  after  the  ingestion  of  some  chemical 
caustic  substance,  or  a  scalding  fluid  may  act  in  the  same  manner.  From  a 
surgical  standpoint  toxic  esophagitis  is  the  most  important  inflammation  of 
the  esophagus,  because  of  the  complications  which  are  apt  to  follow,  especially 
the  formation  of  strictures.  In  cases  where  the  injury  is  only  superficial,  the 
epithelial  layer  may  be  thrown  off  without  any  complications  following.  Where 
the  erosion  is  deep,  causing  a  slough  of  the  entire  thickness  of  the  mucosa, 
and  perhaps  some  of  the  muscular  coat,  the  inflammation  may  extend  beyond 
the  esophagus,  forming  a  peri-esophageal  abscess  extending  into  the  medias- 
tinum. The  eroded  area  undergoes  cicatrization  after  the  slough  is  thrown 
off  and  as  a  result  of  the  contraction  of  this  scar  a  stricture  is  apt  to  follow. 
Swallowing  of  a  large  amount  of  the  concentrated  alkalies  or  acids  is  apt  to 
end  fatally  on  account  of  the  slough  it  usually  causes  in  the  stomach. 


SUEGERY  OF  THE  ESOPHAGUS  AND  STOMACH      407 

The  authors  recently  had  a  case  of  a  ■woman  'WTio  tried  to  commit  suicide  by  swallowing' 
one  ounce  of  strong  hydrochloric  acid.  The  patient  was  remarkably  free  from  esophageal 
symptoms,  but  nine  days  after  the  ingestion  of  the  acid  she  vomited  a  large  roll  of  tissue, 
which  proved  to  be  a  considerable  portion  of  the  mucous  lining  of  the  stomach.  The  tissue 
was  in  one  piece,  was  somewhat  gangrenous  in  appearance  and  measured  fifty  square  inches. 
The  patient  was  kept  on  liquid  food  and  had  no  symptom  referable  to  the  esophagus,  but 
complained  some  of  a  burning  pain  in  the  stomach.  After  about  four  weeks  she  began  to 
lose  in  weight  rapidly  and  every  second  or  third  day  would  vomit  a  large  amount  of  dark 
fluid.  We  first  saw  the  patient  twelve  weeks  after  the  swallowing  of  the  acid.  At  this  time 
she  complained  of  a  large  swelling  in  the  abdomen,  which  she  said  seemed  like  a  large  sac 
of  water.  The  patient  was  greatly  emaciated  and  on  examination  there  was  a  soft  mass 
extending  from  the  epigastrium  to  the  symphysis  pubis.  A  distinct  splashing  sound  could 
be  elicited  and  a  peristaltic  wave  seen  beginning  in  the  left  inguinal  region  and  extending  to 
the  region  of  the  pylorus.  A  stomach  tube  was  inserted  which  passed  easily,  and  five  quarts 
of  a  dark  brownish  fluid  was  withdrawn.  The  patient  was  placed  on  rectal  feeding  and 
gastric  lavage  was  used  three  times  daily  for  three  days.  At  this  time  a  laparotomy  was  per- 
formed. The  stomach  had  contracted  to  the  level  of  the  umbilicus  and  there  was  a  cicatricial 
mass  in  the  pyloric  end,  causing  practically  a  complete  obstruction  of  the  pylorus.  A  gastro- 
enterostomy was  performed.  The  patient  did  very  well  for  nine  days,  when  she  died  suddenly 
from  pulmonary  embolism.  Examination  of  the  esophagus  at  the  post-mortem  showed  no 
evidence  of  injury  from  the  swallowing  of  the  acid. 

Treatment.  The  treatment  of  corrosive  esophagitis  is  principally  sympto- 
matic at  first.  Rectal  feeding,  ice,  narcotics.  Examination  with  bougies  should 
not  be  undertaken  as  long  as  there  is  any  evidence  of  recent  ulceration.  Such 
ulcerations  usuallj^  continue  from  two  to  four  weeks,  according  to  the  degree 
of  the  burn.  After  four  weeks  bougies  may  be  passed  as  a  prophylactic  meas- 
ure against  the  formation  of  strictures. 

PHLEGMON  OF  THE  ESOPHAGUS 

Phlegmonous  inflammation  of  the  esophagus  is  of  rare  occurrence.  This 
purulent  inflammation  may  occur  after  penetrating  injuries,  and  injuries 
caused  by  caustics  or  from  extension  from  abscess  of  the  stomach,  and  by 
rupture  of  a  peri-esophageal  abscess.  The  inflammation  may  be  circumscribed 
or  diffuse,  extending  over  large  areas.  Abscesses  may  form  with  bulging  of 
the  mucous  membrane  of  the  esophagus,  causing  an  obstruction.  These  ab- 
scesses usually  rupture  spontaneously  into  the  esophagus.  The  symptoms  in 
these  cases  vary ;  fever,  chills,  difficulty  in  swallowing,  pain  along  the  course 
of  the  esophagus,  especially  behind  the  sternum.  There  may  be  coughing  and 
regurgitation  of  pus  if  there  is  abscess  formation.  The  treatment  is  ordinarily 
symptomatic,  but  some  authors  suggest  esophagoscopy  and  incision  in  case 
of  abscess  formation. 

ULCER  OF  THE  ESOPHAGUS 

Various  forms  of  ulceration  are  met  with  in  the  esophagus :  gangrenous 
ulcers  from  pressure,  syphilitic,  tubercular  and  the  peptic  or  round  ulcers. 
Gangrenous  ulcers  may  be  caused  by  pressure  from  within  or  from  without. 
Goitre  or  some  other  tumor  may  make  pressure  upon  the  cricoid  or  one  of  the 
tracheal  rings,  causing  pressure  on  the  esophagus,  resulting  in  a  necrosis  of 
one  or  both  of  the  walls.  Aneurysm  of  the  aorta  may  act  in  the  same  manner, 
also  foreign  bodies  from  within. 

Syphilitic  ulcers  may  occur  in  the  esophagus,  but  are  very  rare.  They 
usually  are  situated  in  the  upper  portion  of  the  tube.  The  lesion  is  usually 
a  gumma,  and  frequently  results  in  scar  formation,  causing  constriction.  In 
many  cases  the  diagnosis  is  made  by  noticing  the  effect  of  anti-syphilitic 
treatment. 

The  occurrence  of  tuberculous  ulcers  has  recently  been  positively  deter- 
mined, but  they  are  very  rare. 


408      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Peptic  or  round  ulcers,  analogous  to  those  found  in  the  stomach,  occa- 
sionally are  found  in  the  esophagus.  They  are  frequently  associated  with 
ulcers  of  the  stomach  and  are  situated  in  the  lower  portion  of  the  esophagus. 
They  may  or  may  not  cause  symptoms,  but  when  present  they  are  similar  to 
those  of  gastric  ulcer. 

NEW  GROWTHS  OF  THE  ESOPHAGUS 

Carcinoma  is  the  most  frequent  of  the  new  growths  of  the  esophagus, 
in  fact  it  is  the  most  common  disease  met  with  m  the  esophagus,  it  may 
occur  either  primary  or  secondary.  When  secondary  it  usually  occurs  by 
direct  extension  from  neighboring  organs.  It  may  occur  through  inoculation 
from  the  secretion  of  a  carcinomatous  ulcer  higher  up  in  the  gastro-intestinal 
tract. 

Carcinoma  of  the  esophagus  is  most  common  in  the  male  and,  the  same 
as  other  carcinomas,  is  usually  a  disease  of  advanced  life. 

It  is  usually  situated  at  one  of  the  normal  constrictions  of  the  esophagus 
corresponding  to  the  cricoid  cartilage,  the  bifurcation  of  the  trachea  and  the 
hiatus  of  the  esophagus.  This  fact  rather  favors  the  view  that  there  may  be 
some  connection  between  repeated  irritations  and  the  development  of  carci- 
noma, as  these  portions  of  the  esophagus  are  constantly  subjected  to  irritation 
more  than  the  rest  of  the  canal. 

Strictures  are  also  most  common  at  these  points,  so  it  is  possible  that 
carcinoma  develops  in  a  cicatricial  stricture  or  some  other  scar. 

It  is  estimated  that  about  hfty  per  cent,  of  the  cases  of  esophageal  car- 
cinoma occur  at  the  cardia,  or  just  above  where  the  esophagus  passes  through 
the  diaphragm.  About  forty  per  cent,  are  found  near  the  bifurcation  of  the 
trachea,  and  less  than  ten  per  cent,  in  the  cervical  portion  of  the  esophagus. 

Symptoms.  The  most  important  and  usually  the  earliest  symptom  of  car- 
cinoma of  the  esophagus  is  dysphagia.  The  manifestations  are  those  of  a 
slowly-advancing  stenosis.  The  patient  usually  comes  giving  a  history  of 
having  been  in  good  health  until  a  few  mouths  before,  when  he  began  to  have 
some  difticulty  in  swallowing  meat  or  other  coarse  food.  This  condition  grad- 
ually becomes  worse,  when  the  patient  has  difficulty  in  swallowing  soft  foods, 
and  finally  confines  himself  solely  to  liquid  food.  Usually  by  the  time  the 
patient  consults  a  surgeon  he  has  lived  on  liquids  for  a  considerable  period 
on  account  of  the  difficulty  of  swallowing  solids.  Coincidentally  with  the 
difficulty  of  swallowing,  there  is  usually  a  sense  of  weakness  and  a  progres- 
sive loss  of  weight. 

Considerable  improvement  may  be  noted  upon  the  administration  of  non- 
irritating  liquid  foods.  A  gain  of  several  pounds  is  possible  for  a  short  time 
by  giving  an  abundance  of  milk,  cream  and  raw  eggs.  There  is  seldom  any 
vomiting,  but  usually  a  regurgitation  of  food  and  large  quantities  of  mucus. 
This  regurgitation  may  take  place  very  quietly  and  is  entirely  diiferent  from 
vomiting.  In  the  later  stages  the  accumulation  of  thick,  tenacious  mucus  above 
the  stenosis  may  cause  gagging  and  retching,  which  is  very  annoying. 

It  is  not  uncommon  to  have  some  hoarseness  rather  early,  gradually  becom- 
ing more  pronounced  on  account  of  the  further  involvement  of  the  recurrent 
laryngeal  nerve. 

As  a  rule  there  is  more  or  less  pain  associated  with  carcinoma  of  the 
esophagus.  This  is  described  as  a  sense  of  burning  or  pressure  in  the  throat 
or  chest,  especially  during  swallowing.  Occasionally  the  pain  precedes  the 
dysphagia.  It  is  frequently  felt  in  the  back,  radiating  to  the  shoulders  and 
the  back  of  the  neck.  The  loss  of  weight  and  strength  in  these  cases  is  at 
first  due  to  the  dysphagia,  and  later  they  result  also  from  the  malignant 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


409 


Elastic  Dilating  Bougie  Especially  Designed  eor  Esophageal  Stkicture. 

1,  Graduated  flexible  bougie  hollow,  made  of  spiral  steel;  2,  Lead  rod  to  be  placed  in 
lumen  of  1  enabling  the  operator  to  give  the  bougie  definite  curves;  3,  Short;  4,  Long,  fili- 
form bougie  to  be  screwed  into  the  distal  end  of  1. 


410  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

pathological  process.  In  advanced  instances  it  is  not  uncommon  to  have  a 
contracted  pupil  on  one  side.  According  to  Hitzig  this  is  found  in  about 
one-sixth  of  the  cases.  The  left  pupil  is  most  frequently  involved.  It  is  due 
to  pressure  upon  the  sympathetic  nerve. 

While  an  involvement  of  the  recurrent  nerves  may  occasionally  be  found 
as  an  early  symptom,  it  most  often  means  that  the  disease  has  made  consid- 
erable progress.  The  pressure  may  be  due  to  the  growth  itself,  but  is  probably 
most  often  due  to  an  involvement  of  the  lymphatic  glands. 

Besides  hoarseness,  this  pressure  may  cause  attacks  of  dj'spnea. 

Diagnosis.  By  taking  a  careful  history  one  can  usually  obtain  many  im- 
portant diagnostic  points. 

In  a  patient  with  slowly-progressing  stenosis,  and  the  absence  of  any 
traumatic,  specific  or  other  etiological  factor,  the  obstruction  is  more  apt  to 
be  due  to  new  growth  than  to  a  cicatricial  stenosis.  Then  if  the  patient  be 
past  forty  years  of  age,  is  a  male  and  the  above-mentioned  symptoms  are 
present,  with  emaciation  and  cachexia,  the  diagnosis  of  carcinoma  is  fairly 
certain. 

On  palpation  there  is  occasionally  a  tumor  or  induration  felt  in  the  neck. 
This  may  be  the  primary  growth,  but  most  often  it  is  metastases  of  the  lym- 
phatic glands.  Examination  with  bougies  may  further  aid  in  the  diagnosis 
by  determining  the  existence  of  an  obstruction  and  its  location.  This  exami- 
nation may  prove  negative  even  though  a  carcinoma  be  present.  The  growth 
may  be  so  small  that  the  bougie  may  glide  past  without  otfering  a  definite 
resistance.  A  negative  examination  may  also  be  due  to  the  fact  that  necrosis 
has  taken  place,  and  the  position  of  the  growth  projecting  into  the  lumen 
of  the  esophagus  may  grow  only  in  the  long  axis  of  the  tube,  so  that  it  causes 
no  marked  obstruction.  When  ulceration  has  taken  place  more  can  often  be 
determined  by  passing  a  stomach  tube  or  hollow  bougie,  as  particles  of  tissue 
may  become  caught  in  the  fenestrum  of  the  tnbe  and  the  diagnosis  positive!}' 
determined  by  the  examination  of  such  fragments. 

It  is  often  difficult  to  differentiate  between  carcinoma  of  the  esophagus 
and  aneurysm  of  the  aorta. 

If  one  will  bear  in  mind  the  arrangement  of  the  lymphatic  glands  of  the 
mediastinum,  he  can  readily  perceive  how  two  conditions  so  diverse  as  an 
aneurysm  of  the  aorta  and  carcinoma  of  the  esophagus  may  cause  almost 
identical  symptoms. 

The  lymphatic  glands  are  in  actual  contact  with  the  esophagus,  so  that 
often  secondary  involvement  occurs  very  early.  This  being  the  case,  we  have 
a  tumor  growth  in  the  mediastinum  which  may  cause  the  ordinary  signs  and 
symptoms  produced  by  aneurysm  in  the  same  location.  The  glands  may 
enlarge  so  much  more  rapidly  than  the  primary  tumor  that  there  may  be 
symptoms  of  intra-thoracic  pressure  before  there  are  any  signs  of  obstruction 
of  the  esophagus.  In  such  a  case  as  this,  the  sj'mptoms  would  naturally  be 
the  same  in  both  conditions,  being  due  to  pressure  on  the  same  structures. 

Dyspnea,  which  is  a  fairly  constant  sign  in  case  of  aneurysm  of  the  aorta, 
is  almost  as  constant  a  sign  in  carcinoma  of  the  esophagus.  In  both  the 
aneurysm  and  the  mediastinal  metastasis  from  the  esophageal  cancer  the 
dyspnea  is  due  to  pressure  on  the  bronchi  or  trachea.  Dysphagia  very 
naturally  causes  the  surgeon  to  think  that  he  is  dealing  with  a  growth  of  the 
esophagus,  but  in  many  cases  of  aneurysm  of  the  aorta  the  esophagus  is  affected 
sufficiently  to  cause  dj'sphagia.  Even  though  the  aneurysm  does  not  press 
directly  on  the  esophagus,  it  maj^  cause  dysphagia  by  pressure  'on  the  vagus, 
or  its  esophageal  branches. 

Thus  we  see  that  it  is  often  difficult  to  differentiate  between  carcinoma 
of  the  esophagus  and  aneurysm  of  the  aorta,  when  the  growth  is  situated 


SURGERY  OF  THE  ESOPHAGUS  AND  STO]\IACH  411 

in  the  thoracic  portion  of  the  esophagus,  especially  if  there  is  an  early  involve- 
ment of  the  mediastinal  glands. 

Prognosis.  The  prognosis  of  carcinoma  of  the  esophagus  is  always  unfa- 
vorable. So  far  as  known  no  permanent  cures  have  been  effected  even  after 
resection.  The  average  duration  of  the  disease  is  from  six  months  to  two 
3-ears.  The  majority  of  the  cases  usually  succumb  one  year  after  the  mani- 
festations of  the  disease. 

Death  usually  takes  place  slowly  from  inanition  and  carcinomatous 
cachexia,  or  there  may  be  the  typical  picture  of  pyemia.  Where  there  is  a 
perforation  and  rupture  into  the  air  passages,  death  takes  place  from  pneu- 
monia or  gangrene  of  the  lung.  Occasionally  these  patients  meet  with  a  rapid 
and  sudden  death  from  erosion  and  rupture  into  the  large  blood  vessels. 

Treatment.  The  treatment  comprises  the  following  non-operative  pro- 
cedures, viz.,  dilatation  with  bougies  and  dilation  by  permanent  tubage.  The 
operative  methods  are  resection  of  the  esophagus ;  esophagostomy  and  gas- 
trostomy. 

Dilatation.  Dilatation  with  bougies  is  quite  generally  employed,  especially 
by  the  general  practitioner.  This  is  usualh^  successful  for  a  time,  as  the  soft 
carcinomatous  tissue  yields  readily.  This  form  of  treatment  is  often  unavoid- 
able as  the  patient  will  not  consent  to  the  operative  procedures.  It  should  be 
borne  in  mind  that  the  bougies  cause  mechanical  irritation,  and  that  the  growth 
may  be  excited  by  their  use.  Great  care  should  be  exercised  in  the  use  of  the 
bougies  on  account  of  danger  of  perforating  into  the  neighboring  organs  dur- 
ing the  procedure. 

The  conical-shaped  English  bougies  are  the  best  for  this  purpose,  as  they 
are  soft  and  pliable.  The  bougies  are  introduced  as  described  above.  Occa- 
sionally the  carcinomatous  stricture  will  be  so  small  that  it  will  be  impossible 
to  pass  the  bougie  through  it.  Then  a  filiform  bougie  may  be  passed,  to  the 
end  of  which  is  attached  a  conical  spiral  bougie  shown  in  the  plate.  "When 
this  is  withdrawn  a  small-sized  English  bougie  is  passed,  followed  by  the 
larger  sizes.    Some  temporary  relief  is  aft'orded  in  this  manner. 

Permanent  dilation  by  introducing  a  hard  rubber  tube  into  the  stricture  is 
seldom  used.  Unpleasant  accidents  may  occur,  such  as  breaking  or  swallowing 
the  string,  and  the  constant  presence  of  the  string  in  the  mouth  is  very  annoy- 
ing to  the  patient. 

Resection  of  the  esophagus.  The  majority  of  cases  of  carcinoma  of  the 
esophagus  are  not  accessible  to  radical  treatment.  The  authors  have  had  no 
personal  experience  in  resection  of  the  esophagus  for  carcinoma.  In  the  few 
cases  recorded  in  the  literature  of  the  subject  the  immediate  mortality  is  high 
and  the  relief  in  the  other  cases  was  only  transitory. 

It  is  quite  probable  that  with  further  development  of  Sauerb ruck's  method 
of  operating  within  a  pneumatic  cabinet  under  negative  pressure,  a  satisfactory 
operation  for  resection  of  the  esophagus  in  cases  of  carcinoma  may  be  made 
possible. 

Esophagostomy.  Esophagostomy  is  occasionally  performed  and  the  patient 
fed  through  this  fistulous  opening.  This  operation  is  applicable  only  in  eases 
of  carcinoma  situated  high  up  in  the  cervical  portion  where  the  opening  can  be 
made  below  the  stricture.  It  is  doubtful  whether  feeding  through  an  esoph- 
ageal fistula  is  less  annoying  to  the  patient  than  through  a  gastrostomy  open- 
ing; the  detail  of  the  latter  proceeding  being  much  easier  for  the  patient  to 
carry  out  himself.  As  a  rule  a  gastrostomy  is  preferable  to  an  esophagostomy 
as  a  means  of  these  patients  taking  nourishment. 

The  technique  of  esophagostomy  is  described  under  the  subject  of  foreign 
bodies  in  the  esophagus.  » 


Gastrostomy. 

A  represents  the  stomacli  wall  drawn  out  through  the  abdominal  incision,  with  two  cir-i 
cular  purse-string  sutures  in  position. 

B  is  the  same  as  plate  A,  with  retention  catheter  introduced  through  an  opening  which 
has  been  made  in  thet  center  of  the  circle  formed  by  the  purse-string  sutures.  The  portioi 
contained  within  this  circle  has  been  inverted  into  the  cavity  of  tl;e  stomach  and  the  sutures 
have  lieen  tied  and  cut  short. 


C 


D 


C  represents  the  manner  of  attaching  the  stomach  to  the  abdominal  wall  by  means  of  cat- 
gut sutures,  uniting  the  stomach  to  the  parietal  peritoneum  and  transversalis  fascia.  Two 
deep  silkworm  gut  sutures,  which  extend  through  the  entire  abdominal  wall,  grasp  the  wall 
of  the  stomach  in  order  to  act  as  stay  sutures. 

D  is  the  same  as  plate  C  with  the  addition  of  a  piece  of  iodoform  gauze  folded  about 
the  retention  catheter  and  attached  to  the  wall  of  the  stomach  by  interrujjted  cat-gut  sutures, 
in  order  to  make  the  adhesion  to  the  abdominal  wall  more  secure. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      413 

Gastrostomy  is  indicated  where  the  patient  cannot  take  enough  food  by 
mouth,  as  is  shown  by  rapid  emaciation.  The  earlier  the  operation  is  per- 
formed, the  more  satisfactory  will  be  the  result.  If  a  positive  diagnosis  of 
carcinoma  is  made,  a  gastrostomy  should  be  done,  even  though  the  patient  can 
still  swallow  liquids.  Of  course  a  gastrostomy  cannot  stop  the  progress  of  the 
disease,  but  it  may  inhibit  ichorous  decomposition,  which  is  caused  by  food 
remaining  in  the  ulcerated  area.  As  a  result  of  the  operation  the  carcinoma 
may  grow  less  rapidly,  because  the  continuous  irritation  from  the  passage  of 
food  has  been  relieved.  Oftentimes  both  physicians  and  surgeons  decide  upon 
an  operation  too  late.  This  accounts  for  the  fact  that  the  mortality  is  rather 
high  in  this  operation.  If  gastrostomy  is  performed  at  the  proper  time,  the 
life  of  the  patient  may  be  prolonged  for  several  months,  or  even  more  than  a 
year. 

In  choosing  the  operation  it  is  necessary  to  select  a  method  which  may  be 
rapidly  carried  out  and  at  the  same  time  effect  a  closure  of  the  fistula. 

Preparatory  treatment.  If  the  obstruction  is  complete  the  operation  should 
be  done  at  once  after  securing  an  evacuation  of  the  bowels  by  means  of  a  large 
enema.  So  long  as  there  is  still  a  slight  passage  in  the  obstruction  it  is  well  to 
administer  some  saline  mineral  water  freely  every  morning  for  several  days,  in 
order  to  secure  a  free  evacuation  of  the  bowels,  because  one  frequently  finds 
large  accumulations  in  the  colon  in  these  cases,  as  they  have  usually  been  con- 
stipated for  a  long  time,  and  they  will  bear  an  operation -much  better  if  there 
is  no  decomposing  substance  in  any  part  of  the  intestinal  canal. 

If  the  patient  is  very  weak  it  is  frequently  possible  to  increase  his  strength 
considerably  by  giving  some  of  the  various  concentrated  predigested  foods  in 
considerable  quantities  at  regular  intervals  of  two  or  three  hours  for  a  few 
days.  Ordinarily,  however,  they  bear  the  operation  well  if  performed  rapidly 
and  with  a  minimum  amount  of  traumatism,  so  that  it  is  only  necessary  to  give 
the  above  preparatory  treatment  to  patients  who  have  had  little  or  no  care 
previous  to  their  admission  to  the  hospital. 

The  field  of  operation  is  prepared  as  in  every  abdominal  operation. 

Technique.  The  incision  is  made  through  the  outer  edge  of  the  left  rectus 
abdominis  muscle  from  one-half  to  three  inches  in  length.  The  length  of  the 
incision  will  depend  upon  the  extent  of  the  contraction  of  the  stomach  and  the 
thickness  of  the  stomach  wall.  In  case  of  a  contracted  stomach  with  a  thick 
wall,  it  is  necessary  to  make  the  incision  longer  than  where  there  is  a  large, 
thin-walled  stomach,  so  as  to  secure  a  sufficient  amount  of  space  to  conduct  the 
necessary  manipulations  without  causing  too  much  traumatism.  As  soon  as 
the  abdomen  has  been  Opened  a  portion  of  the  anterior  wall  of  the  stomach  is 
drawn  into  the  wound  and  two  purse-string  stitches  of  fine  silk  or  linen  are 
applied,  as  shown  in  the  plate ;  the  circle  described  by  the  first  stitch  being 
about  three-fourths  of  an  inch  in  diameter.  In  each  case  a  little  more  than  a 
full  circle  is  described,  in  order  to  provide  against  a  possible  defect.  These 
stitches  grasp  all  of  the  layers  of  the  stomach  down  to  the  mucous  membrane, 
including  the  submucous  connective  tissue.  The  space  within  the  inner  circle 
is  now  punctured  with  a  trocar,  and  a  tube  from  one-quarter  to  one-half  an 
inch  in  diameter  made  out  of  rather  stifi^,  pure  rubber,  fashioned  after  the  pat- 
tern of  a  Jacob's  retention  catheter,  is  inserted  into  this  opening.  This  will 
produce  an  infolding  of  the  stomach  wall,  which  is  still  further  exaggerated 
when  the  purse-string  sutures  are  tied. 

The  enlargement  at  the  end  of  the  tube  prevents  its  slipping  out  of  the 
opening,  and  the  close  application  of  the  serous  surface  to  the  tube  prevents 
any  leakage.  This  condition  is  still  further  enforced  by  the  application  of  sev- 
eral rows  of  Lembert  sutures  to  each  side  of  the  tube,  as  shown  in  accompany- 
ing plate. 


414  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

In  a  thin-walled  stomach  it  may  be  desirable  to  apply  four  or  five  rows  of 
these  interrupted  sutures,  while  in  a  thick-walled  stomach  two  or  three  rows 
outside  of  the  purse-string  sutures  will  suffice.  The  end  of  the  tube  in  the 
stomach  should  be  closed  with  a  cork  or  clamped  with  a  convenient  con- 
trivance, so  that  no  stomach  contents  may  be  expelled  during  the  course  of 
the  operation.  The  important  condition  to  be  obtained  is  a  provision  against 
leakage,  which  the  above-described  method  has  always  accomplished  in  a  most 
satisfactory  manner. 

The  next  step  is  the  attachment  of  the  stomach  to  the  abdominal  wall. 
This  is  accomplished  by  first  inserting  silk-worm  gut  sutures  through  all  the 
layers  of  the  abdominal  wall,  then  all  the  layers  of  the  stomach  wall  down  to 
the  mucous  membrane,  then  out  through  all  of  the  layers  of  the  abdominal  wall 
on  the  opposite  side.  Then  the  stomach  wall  is  sutured  to  the  peritoneum  and 
transversalis  fascia  by  a  number  of  interrupted  sutures.  The  abdominal  Avound 
is  then  closed  in  the  usual  manner  by  suturing  each  layer  separately,  the  feed- 
ing tube  being  permitted  to  pass  out  through  the  middle  of  the  wound.  A 
dry,  sterile  gauze  dressing  is  applied,  the  tube  being  permitted  to  pass  out 
through  the  center  of  the  dressing  and  the  binder  holding  the  dressing  in  place, 
so  that  the  patient  may  be  fed  without  disturbing  the  dressing. 

In  some  of  these  patients  who  have  become  much  reduced  in  strength,  the 
adhesions  formed  between  the  stomach  and  the  abdominal  wall  are  very  frail 
unless  increased  by  means  of  some  irritation.  For  this  purpose  the  use  of 
iodoform  gauze  has  proven  very  satisfactory,  it  being  applied  in  the  follow- 
ing manner:  A  piece  of  iodoform  gauze  is  folded  around  the  feeding  tube 
and  stitched  to  the  stomach  by  a  number  of  interrupted  catgut  sutures.  All 
of  the  other  steps  of  the  operation  are  carried  out  as  above,  this  simply  being 
an  additional  safeguard.  After  about  ten  days  the  catgut  sutures  will  be 
absorbed  and  the  gauze  may  be  withdrawn.  It  will  usually  be  found  quite 
adherent  and  the  adhesions  between  the  stomach  and  the  abdominal  wall  will 
have  become  exceedingly  firm  by  this  time. 

After-treatment.  If  the  obstruction  has  been  complete  or  nearly  so,  and  the 
patient  suffered  severely  from  thirst  before  the  operation,  half  a  pint  of  warm, 
normal  salt  solution  should  be  poured  into  the  stomach  through  the  feeding 
tube  at  the  close  of  the  operation,  and  this  should  be  repeated  every  half  hour 
until  the  patient  is  satisfied.  If  he  had  been  able  to  swallow  before  the  opera- 
tion, he  may  be  allowed  to  drink  water  naturally  after  the  procedure  if  this 
causes  no  distress  or  annoyance ;  otherwise  it  is  to  be  given  through  the  feeding 
tube  entirely.  After  a  time  the  absence  of  irritation  may  cause  a  disappear- 
ance of  the  complete  obstruction  and  then  the  patient  will  again  be  able  to 
take  liquids  by  mouth.  In  the  meantime  he  should  be  fed  regularly  every 
three  hours  with  peptonized  milk,  raw  egg,  the  juice  extracted  from  roast  beef 
or  broiled  steak,  rich  broths,  soups  and  mush.  The  food  may  be  poured  into 
the  stomach  through  a  funnel,  or  an  ordinary  glass  syringe  may  be  attached  to 
the  feeding  tube  and  this  will  serve  as  a  funnel. 

Later  the  patient  may  chew  any  kind  of  food  very  fine,  and  thus  mix  it  with 
saliva.  He  can  then  inject  this  through  the  feeding  tube  into  the  stomach. 
These  patients  can  thus  improve  their  digestion,  especially  of  starchy  food, 
and  may  continue  enjoying  their  meals  in  this  way. 

Almost  invariably  these  patients  gain  rapidly  in  weight  and  strength, 
because  the  enforced  rest  of  the  stomach  and  intestines  has  usually  placed 
these  organs  in  a  condition  in  which  they  can  thoroughly  digest  an  abundance 
of  food.  We  have  repeatedly  observed  these  sufferers  gain  sufficiently  in 
strength  in  a  few  weeks  to  enable  them  to  do  hard  labor,  which  was  continued 
until  the  carcinoma  had  implicated  some  other  important  organ,  either  by 
invasion  or  by  the  formation  of  metastasis.  , 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      415 

It  is,  of  course,  necessary  to  explain  to  the  friends  of  the  patient  that  this 
operation  cannot  result  in  a  cure  of  the  disease,  but  that  it  can  simply  give 
temporary  relief.  This  relief,  however,  is  so  great,  and  the  risk  in  obtaining 
it  is  so  slight,  that  it  is  an  operation  which  may  be  very  strongly  recommended. 
Aside  from  the  distress  due  to  hunger,  and  especially  to  thirst,  patients  afflicted 
with  obstruction  of  the  esophagus  suffer  pain  but  slightly,  consequently  the 
relief  given  by  this  operation  is  relatively  very  complete. 

CYSTS,  PAPILLOMATA,  MYOMATA  AND  SARCOMATA  OF  THE 

ESOPHAGUS 

Many  of  the  growths  occurring  in  the  esophagus,  such  as  warts,  cysts, 
papillomata,  fibromata,  lipomata,  possess  only  a  pathological  interest,  as  they 
rarely  cause  disturbance. 

Klebs  has  pointed  out  the  analogy  between  diseases  of  the  esophagus  and 
those  of  the  skin.  Thus  in  the  esophagus  are  found  warts  which  are  usually 
small  and  spread  over  different  portions  of  the  tract.  It  would  seem  probable 
that  these  warts  might  develop  into  carcinoma  as  is  seen  in  skin  warts,  but  so 
far  such  an  event  has  never  been  demonstrated. 

Retention  cysts  of  the  mucous  glands  have  also  been  described.  On  account 
of  their  small  size  they  usually  do  not  cause  any  symptoms. 

Fibromata  and  lipomata  also  occur,  but  are  very  rare.  They  are  usually 
autopsy  findings,  as  they  run  their  course  without  producing  symptoms. 

Sarcomata  of  the  esophagus  are  rather  rare  and  the  symptoms  and  course 
of  the  disease  are  similar  to  those  of  carcinoma.  A  positive  diagnosis  can  only 
be  made  by  securing  a  portion  of  the  tissue  for  microscopical  examination. 
The  treatment  is  the  same  as  described  for  carcinoma. 

Pedunculated  tumors  of  the  esophagus  are  classified  as  polypi.  They  are 
rather  rare.  They  are  usually  attached  to  the  upper  end  of  the  esophagus  in 
the  region  of  the  cricoid  cartilage.  Small  polypi  cause  no  symptoms.  The 
larger  ones  may  cause  difficulty  in  swallowing  and  occasionally  the  distal  end 
of  the  polypus  is  thrown  upwards  into  the  throat,  causing  choking  and  diffi- 
culty in  breathing. 

INJURIES  OF  THE  ESOPHAGUS 

Trauma  from  an  internal  source.  The  injuries  of  the  esophagus  produced 
by  violence  from  within  are  those  resulting  from  swallowing  various  corrosive 
drugs,  from  foreign  bodies  that  have  been  swallowed,  also  by  passing  bougies, 
coin-catchers  and  other 'instruments.  Injuries  from  the  passing  of  instruments 
are  particularly  liable  to  occur  in  the  presence  of  pathological  changes  such  as 
carcinoma,  ulcer,  stricture,  etc.  Perforation  of  the  esophagus  is  a  serious 
condition,  as  it  may  result  in  a  fatal  mediastinitis  or  pleuritis. 

Primary  traumatism.  Primary  traumatic  injury  of  the  esophagus  due 
to  the  swallowing  of  hard  substances  such  as  sharp  bones  from  fishes  or  bone 
splinters  is  not  very  common  because  the  mucous  membrane  of  this  organ 
seems  to  be  capable  of  enduring  ordinary  insults. 

Secondary  injury  of  the  esophagus,  from  ulceration  of  the  mucous  mem- 
brane due  to  the  fact  that  some  hard  object  which  has  been  swallowed  and 
become  lodged,  is  not  so  rare.  In  children  these  objects  are  most  commonly 
playthings,  buttons  or  coins ;  in  adults  they  are  more  commonly  bones  or  artifi- 
cial teeth. 

Dangerous  ulceration  is  more  common  if  the  object  is  lodged  at  a  point 
where  it  is  subjected  to  the  impulse  of  the  pulsations  of  the  aorta,  exposing  the 
patient  to  the  risk  of  fatal  hemorrhage.    From  this  it  is  clear  that  it  is  import- 


416      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

ant  in  case  a  hard  object  has  become  lodged  in  the  esophagus  to  locate  it  by 
the  use  of  the  X-ray  and  to  take  the  necessary  steps  for  immediate  removal. 

EXTERNAL  INJURIES  OF  THE  ESOPHAGUS 

The  esophagus  being  so  deeply  situated  injuries  from  violence  from  with- 
out are  extremely  rare.  Wounds  of  the  cervical  portion  are  the  most  common 
and  usually  occur  as  a  result  of  attempted  suicide. 

These  wounds  are  usually  high  up  on  the  neck  in  the  region  of  the  larynx 
or  hyoid  bone,  so  that  the  wound  of  the  alimentary  canal  is  either  high  up  in 
the  esophagus  or  in  the  pharynx.  In  these  cases  the  respiratory  passages  are 
practically  always  injured  at  the  same  time. 

Injury  of  the  esophagus  alone  in  the  thoracic  portion  is  extremely  rare. 
This  may  result  from  daggers,  bayonets  or  bullets.  Injuries  of  adjacent  organs, 
as  heart,  lungs,  large  vessels,  etc.,  which  are  usually  fatal  in  themselves  on 
account  of  their  character  and  anatomical  position,  are  apt  to  occur  at  the 
same  time.  The  danger  from  injury  to  the  esophagus  is  in  itself  very  critical 
on  account  of  the  escape  of  food  into  the  surrounding  tissues,  resulting  in 
ichorous  abscesses,  mediastinitis  or  pleuritis. 

Treatment,  When  the  injury  is  in  the  cervical  portion,  the  first  thing  is 
to  control  the  hemorrhage  and  to  avoid  asphyxia.  It  frequently  is  necessary 
to  perform  a  tracheotomy.  If  the  condition  is  such  as  to  warrant  an  opera- 
tion an  attempt  should  be  made  to  suture  the  esophagus,  also  the  trachea  if 
that  has  been  severed.  The  best  method  is  that  employed  in  suturing  the 
intestines,  first  suturing  the  mucous  membrane  and  then  the  muscular  coat 
•  over  this. 

Should  the  injury  be  in  the  thoracic  portion  the  treatment  is  practically 
hopeless,  being  usually  limited  to  feeding  the  patient  per  rectum  or  through 
a  stomach  tube,  if  this  can  be  passed  down  through  the  injured  portion.  If 
the  patient  is  able  to  stand  an  operation  a  gastrostomy  will  be  the  best 
method  of  feeding. 

FOREIGN  BODIES  IN  THE  ESOPHAGUS 

The  lodgment  of  foreign  bodies  in  the  esophagus  is  not  an  uncommon 
condition  and  is  classed  as  one  of  the  emergencies  in  the  practice  of  surgery, 
as  they  frequently  require  prompt  action  on  the  part  of  the  surgeon.  The 
accident  is  most  often  seen  in  the  very  young  and  the  insane.  The  foreign 
bodies  most  often  found  are  coins,  buttons,  pins,  keys,  glass  beads,  bones  and 
various  kinds  of  small  toys.  Foreign  bodies  are  frequently  found  in  food, 
such  as  fish-bones,  fruit-stones,  pieces  of  glass  and  enamel.  In  adults  the 
most  frequent  foreign  body  found  in  the  esophagus  is  a  poorly-fitted  dental 
plate  which  had  not  been  removed  at  night  or  which  had  been  swallowed 
during  an  attack  of  syncope  or  convulsions. 

From  what  has  been  said  one  can  see  what  a  great  variety  of  foreign 
bodies  may  enter  into  consideration.  The  situations  at  which  foreign  bodies 
may  become  lodged  depends  considerably  upon  the  nature  and  size  of  the 
object.  Small  pointed  bodies  which  penetrate  the  mucous  membrane  easily 
may  lodge  at  any  point  along  the  esophagus.  Very  large  bodies  as  a  rule 
cannot  pass  the  isthmus  and  remain  lodged  in  the  pharynx.  Small,  sharp- 
pointed  bodies,  like  fish-bones  and  wooden  splinters  which  project  from  a 
morsel  of  food,  are  apt  to  be  driven  into  the  wall  of  the  pharynx  during  the 
first  act  of  swallowing.  Large  bodies  which  pass  the  isthmus  may  become 
impacted  at  the  upper  border  of  the  cricoid  cartilage,  where  the  esophagus 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  417 

is  crossed  by  the  left  bronchus,  or  where  the  esophagus  passes  through  the 
diaphragm. 

Sjnnptoms.  The  symptoms  vary  according  to  the  situation  of  the  object, 
according  to  its  size  and  shape  and  the  amount  of  obstruction  present  and 
also  to  the  amount  of  pressure  exerted  upon  other  organs,  as  the  trachea  or 
larynx.  There  is  usuallj''  nausea,  a  sense  of  obstruction  and  pain  on  attempting 
to  swallow  and  occasionally  a  reflex  cough.  If  the  body  is  large  and  remains 
in  the  pharj^nx  it  may  press  upon  the  opening  in  the  larynx  and  cause  choking, 
accompanied  by  cyanosis,  etc. 

If  there  is  complete  obstruction  all  food  will  be  regurgitated.  AYhen  the 
obstruction  is  high  up  in  the  esophagus  the  regurgitation  will  take  place 
immediately  on  attempting  to  swallow,  if  it  is  low  down  a  little  time  may 
intervene  before  the  food  is  regurgitated. 

In  cases  in  which  the  foreign  body  has  sharp  edges  which  cause  injury 
the  patient  complains  of  a  stabbing  pain  at  a  definite  point  on  attempting  to 
swallow.  This  point  is  apt  to  be  the  location  of  the  obstruction  when  the 
foreign  body  is  situated  high  up. 

When  the  impaction  is  lower  down  the  pain  is  usually  referred  to  the 
region  of  the  sternum,  though  the  obstruction  may  be  at  a  lower  level. 

Diagnosis.  Occasionally  a  positive  diagnosis  of  an  impacted  foreign  body 
can  be  made  from  the  history  and  symptoms.-  On  account  of  the  serious  cora.- 
plications  that  may  arise  from  a  foreign  body  remaining  in  the  esophagus  a 
long  time,  an  attempt  should  be  made  even  in  doubtful  cases  to  determine 
the  presence  or  absence  of  such  a  substance. 

The  pharj^nx  should  be  inspected  by  means  of  a  mirror,  and  palpation 
made  with  the  finger.  External  palpation  should  be  made,  as  large  bodies 
in  the  cervical  portion  can  often  be  felt,  or  there  may  be  a  point  of  tender- 
ness corresponding  to  the  location  of  the  object. 

In  most  cases  a  foreign  body  can  be  found  by  passing  a  bougie,  also  its 
situation  determined  in  this  manner.  The  best  bougie  for  this  purpose  is  a 
whale-bone  staff  with  a  cylindrical  tip  of  ivorj^  or  metal.  On  touching  a 
foreign  body  with  such  an  instrument  a  clicking  or  rubbing  sound  can  be 
heard  or  at  least  felt. 

Examination  with  the  X-ray,  either  by  means  of  the  fluoroscope  or  X-ray 
photograph,  is  an  important  aid  in  diagnosis  and  has  proved  to  be  very  prac- 
ticable in  many  instances. 

The  esophagoscope  may  be  used  in  these  cases  both  as  a  means  of  diagnosis 
and  treatment. 

The  early  use  of  the  esophagoscope  for  the  removal  of  a  foreign  body 
must  be  strongly  urged.  During  the  first  day  or  two  after  a  foreign  body  is 
lodged  there  is  very  little  inflammation  present,  but  after  three  to  four  clays 
or  a  week  inflammation  becomes  intense,  abscess  formation  occurs,  perforation 
of  the  wall  of  the  esophagus  is  apt  to  take  place,  and  above  all,  after  a  short 
time  the  inflammation  surrounding  the  foreign  body  makes  it  difficult  to  ex- 
tract. So  whenever  a  foreign  body  is  lodged  in  the  esophagus  in  an  inacces- 
sible position,  and  when  it  cannot  be  pushed  down  or  brought  up.  the  esophago- 
scope should  be  used  at  once,  and  in  a  great  many  cases  the  foreign  body  can 
thus  be  extracted. 

Treatment.  The  treatment  of  foreign  bodies  should  be  instituted  as  soon 
as  the  diagnosis  has  been  made.  The  various  methods  in  which  no  cutting 
operation  is  concerned  should  be  tried  first,  namely,  extraction  through  the 
mouth,  forcing  the  foreign  body  down  into  the  stomach,  extraction  with  the 
aid  of  the  esophagoscope. 

Extraction  by  the  aid  of  the  esophagoscope.  After  an  examination  of  the 
esophagus  has  been  made  with  a  bougie  and  the  location  of  the  foreign  bodv 


418      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

has  been  determined,  esophagoscopy  should  be  undertaken  with  the  intention 
of  extracting  the  foreign  body  through  the  mouth,  or  pushing  it  into  the 
stomach. 

In  many  cases  a  foreign  body  maj^  be  removed  by  aid  of  the  esophagoscope, 
thus  avoiding  an  esophagotomy  or  possibl}^  a  gastrostomy. 

Esophagostomy  should  only  be  attempted  by  those  who  have  had  special 
training  and  have  mastered  the  technique. 

Pushing  the  object  down  into  the  stomach.  A  foreign  body  should  not  be 
pushed  down  into  the  stomach,  unless  one  is  fairlj^  certain  that  the  procedure 
will  not  be  a  disadvantage  to  the  patient.  The  cases  in  which  this  method  is 
justifiable  are  those  in  which  the  foreign  body  is  smooth  and  is  not  too  large 
to  pass  the  pjdorus,  and  where  it  cannot  be  easily  grasped  with  extraction 
forceps.  Also  in  cases  of  a  soft  body,  as  pieces  of  meat,  potato,  etc.  The  best 
instrument  for  this  purpose  is  the  ordinary  bougie  with  a  cylindrical  tip.  In 
case  a  foreign  body  passes  into  the  stomach,  or  is  pushed  down  into  the 
stomach,  its  passage  will  be  facilitated  bj^  feeding  the  patient  mashed  potatoes 
for  a  few  days. 

AVhere  the  above  methods  are  unsuccessful,  or  in  cases  where  they  are 
contraindicated,  a  surgical  operation  should  be  performed.  Even  though  the 
foreign  body  is  such  that  it  will  not  likely  pass  the  pjdorus  safely,  it  is  justifi- 
able to  push  it  down  into  the  stomach  and  perform  a  gastrotomy  later,  for  the 
latter  operation  is  much  simpler  and  less  dangerous  than  any  external  pro- 
cedure for  impaction  in  the  esophagus. 

There  are  two  methods  of  approach,  one  bj^  an  external  esophagotomy  and 
the  other  by  a  gastrotomy.  The  selection  of  the  method  must  depend  upon  the 
location  of  the  impaction. 

As  a  rule  if  it  is  at  the  cricoid  cartilage  or  any  place  above  the  suprasternal 
notch,  an  esophagotomy  should  be  performed ;  if  below  the  sternal  notch  a 
gastrotomy. 

Esophagotomy.  The  patient  is  anesthetized  and  placed  with  the  shoulders 
well  raised  and  a  sand  bag  under  the  neck  so  as  to  throw  the  head  somewhat 
backwards.  An  incision  is  made  on  the  left  side  of  the  neck  corresponding 
with  the  anterior  border  of  the  sterno-mastoid  muscle.  It  is  carried  directly 
doMai  to  the  muscle.  Blunt  dissection  is  now  used  until  the  anterior  belly  of 
the  myo-hyoid  muscle  is  reached.  This  muscle  and  the  steruo-thyroid  and 
sterno-hyoid  muscles  are  retracted  inwards.  The  lateral  wall  of  the  trachea 
can  now  be  felt  and  on  stretching  the  wound  open  the  esophagus  should  be 
seen  immediately  behind  the  trachea.  Great  assistance  in  locating  the  esoph- 
agus can  be  rendered  by  placing  a  bougie  with  a  large  bulb  in  the  canal  and 
pressing  toward  the  wound.  The  esophagus  is  now  separated  from  its  con- 
nections both  anteriorly  and  posteriorly  by  means  of  blunt  dissection,  so  that 
it  is  possible  to  bring  the  esophagus  iTp  near  the  edges  of  the  skin  wound.  The 
remainder  of  the  wound  is  now  packed  ofif  with  small  pads  so  as  to  prevent 
any  discharge  which  might  come  from  the  esophagus  from  infecting  the  wound. 

An  incision  is  now  made  upon  the  bulb  and  the  cut  edges  of  the  esophagus 
grasped  by  means  of  two  mouse-toothed  forceps.  The  esophagus  is  now 
explored  by  means  of  the  fingers,  and  the  foreign  body  removed  by  the  aid  of  a 
curved  pair  of  esophageal  forceps.  Great  care  should  be  taken  to  sponge  away 
any  mucus  that  escapes  from  the  passage.  After  the  foreign  body  is  removed, 
the  wound  in  the  esophagus  should  be  closed  with  two  layers  of  catgut  sutures, 
the  outer  row  being  Lembert  stitches.  A  small  drain  is  now  carried  down 
to  the  esophagus  and  all  of  the  deep  structures  sutured  in  their  normal  posi- 
tion with  catgut  and  the  skin  approximated  with  horsehair  stitches.  The 
patient  should  receive  no  food  or  liquids  by  mouth  for  a  week  or  ten  days. 
In  well  preserved  patients  the  nourishment  and  fluids  can  be  administered  per 


SURGEEY  OF  THE  ESOPHAGUS  AND  STOMACH  419 

rectum.  In  very  weak  individuals  the  nourishment  may  be  given  by  passing 
a  tube  through  the  nose  down  into  the  stomach. 

The  prognosis  in  cases  of  esophagotomy  depends  mostly  upon  the  time  of 
operation.  If  this  is  done  within  the  first  24  to  48  hours  the  prognosis  is  good. 
If  after  this  time,  and  ulceration  or  perforation  has  taken  place,  the  prognosis 
is  very  grave. 

Gastrotomy.  Eemoval  of  foreign  bodies  through  the  stomach  is  justifiable 
in  all  cases  in  which  such  body  is  situated  too  low  in  the  thoracic  portion  of 
the  esophagus  to  be  reached  by  esophagotomy,  and  which  cannot  be  removed 
by  other  means.  It  is  indicated,  therefore,  where  the  foreign  body  is  situated 
more  than  26  cm.  from  the  teeth,  as  well  as  those  in  the  cardiac  end  of  the 
esophagus,  especially  in  large  angular  or  irregular-shaped  bodies. 

In  performing  gastrotomy  for  foreign  body  in  the  esophagus,  an  incision 
is  made  through  the  edge  of  the  left  rectus  abdominis  muscle  or  obliquely 
along  the  costal  margin.  Upon  opening  the  peritoneal  cavity  the  intestines 
should  be  packed  awaj'-  by  means  of  sterile  gauze  pads  to  guarcl  against  soiling 
the  peritoneum  by  any  leakage  from  the  stomach.  The  dome  of  the  stomach 
is  now  brought  forward  and  out  of  the  peritoneal  cavity  if  possible.  The 
stomach  wall  is  grasped  with  mouse-toothed  stomach  forceps  and  then  incised. 
The  stomach  contents  should  be  removed  by  packing  dry  gauze  pads  in  and 
out  through  the  opening  in  the  stomach  wall.  The  lower  end  of  the  esophagus 
is  now  explored  by  passing  one  finger  through  the  stomach.  The  edges  of  the 
stomach  wound  should  be  held  well  beyond  the  edges  of  the  abdominal  wound 
and  a  pair  of  esophageal  forceps  passed  through  this  opening  up  into  the 
esophagus  and  the  foreign  body  extracted,  if  possible.  In  the  more  difficult 
cases,  where  various  procedures  are  necessary  in  order  to  loosen  and  bring 
down  the  foreign  bodies,  it  is  most  practicable  to  enlarge  the  incision  and 
pass  the  whole  hand  into  the  stomach,  as  recommended  by  Eichardson.  If  the 
foreign  body  cannot  be  reached  with  the  finger  and  removed  by  the  aid  of 
forceps,  the  string  method,  as  used  by  Bull  and  Finney,  should  be  tried.  A 
small  sound  or  bougie  is  passed  either  through  the  mouth,  or  from  below 
through  the  gastrotomy  opening.  A  string  which  has  been  armed  with  a  small 
sponge  or  piece  of  gauze  is  attached  to  the  end  of  the  sound  and  pulled  back 
through  the  esophagus.  An  attempt  is  now  made  by  pulling  this  sponge 
through  the  esophagus  to  bring  the  foreign  body  up  and  out  through  the 
mouth,  or  pull  it  downwards  into  the  stomach.  After  the  foreign  body  has 
been  removed,  the  management  of  the  opening  in  the  stomach  depends  upon 
the  amount  of  traumatism  of  the  esophagus. 

If  the  foreign  body  is  remoA^ed  early  and  with  little  injury  to  the  esopha- 
gus, the  wound  in  the  stomach  should  be  completely  closed  by  first  placing  a 
Connell  suture  through  the  two  edges  and  covering  the  area  with  a  Lembert 
stitch.  In  case  the  foreign  body  has  been  present  for  a  considerable  time  so 
that  it  might  have  caused  an  ulcerated  condition,  or  if  the  esophagus  is  in- 
jured considerably  during  the  removal  of  the  foreign  body,  then  a  temporary 
gastrotomy  should  be  done  for  the  pui*pose  of  administering  food  until  the 
esophagus  has  recovered  from  the  injuries.  The  gastrotomy  should  be  planned 
so  that  the  opening  in  the  stomach  will  close  spontaneously  in  a  short  time. 
This  can  be  accomplished  by  carefully  folding  the  serous  surface  of  the  stomach 
inwards  around  the  feeding  tube  so  there  cannot  possible'  be  any  eversion  of 
the  mucous  lining  of  the  stomach.  If  this  is  done  in  the  manner  indicated  the 
fistula  in  the  stomach  will  close  in  a  short  time  after  removal  of  the  feeding 
tube. 

The  most  important  complications  which  follow  the  swallowing  of  foreign 
bodies  are  hemorrhage  and  phlegmonous  processes  resulting  from  injury  to 
the  esophagus,  ulceration,  perforation  or  gangrene  of  the  esophagus  followed 


420      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

by  a  phlegmonous  process  which  may  lead  to  suppuration  in  the  pleura,  in 
the  mediastinum,  in  the  loose  connective  tissue  between  the  vertebral  column 
and  the  esophagus  or  result  in  pneumonia  or  gangrene  of  the  lungs. 

With  the  existence  of  any  of  the  above  complications  the  prognosis  is 
usually  unfavorable. 

STRICTURE  OF  THE  ESOPHAGUS 

Of  the  actual  strictures  of  the  esophagus,  those  caused  by  carcinoma  are 
most  frequent,  the  next  in  frequency  being  cicatricial  stenosis,  the  result  of 
the  healing  of  an  ulceration.  The  latter  is  produced  by  some  form  of  trau- 
matism, such  as  the  swallowing  of  caustic  alkali,  acids  or  hot  fluids.  It  may 
be  caused  by  a  wound  or  due  to  prolonged  lodgment  of  a  foreign  body.  It  is 
occasionally  due  to  typhoid  ulceration. 

The  most  common  cause,  and  especially  in  children,  is  the  accidental  swal- 
lowing of  concentrated  lye.  In  adults  carbolic  acid,  ammonia,  etc.,  are  fre- 
quently taken,  but  the  immediate  mortality  is  high,  so  only  a  small  proportion 
live  to  develop  a  cicatrix.  Occasionally  the  breaking  down  of  a  syphilitic 
gumma  may  leave  an  ulcer,  and  the  healing  thereof  cause  a  stenosis.  Tuber- 
cular ulceration  of  the  esophasrus  is  very  rare.  The  healing  of  an  ulcer  of  the 
cardia  extending  into  the  esophagus  may  in  rare  cases  result  in  a  cicatricial 
stenosis  of  the  esophagus.  Spasmodic  stricture  of  the  esophagus  is  not  a  rare 
condition  and  must  always  be  kept  in  mind  when  considering  cases  of  obstruc- 
tion of  this  tube. 

A  pressure  stenosis  of  the  esophagus  may  result  from  extra-esophageal  con- 
ditions such  as  tumors  involving  the  thyroid  body,  tracheal  and  mediastinal 
glands,  aneurysms,  pericardial  effusions,  peri-esophageal  abscess  and  spon- 
dylitis. 

Although  strictures  may  occur  at  any  part  of  the  esophagus,  they  are  most 
frequently  found  at  the  site  of  the  three  natural  constrictions,  viz.,  at  the 
entrance,  at  the  level  of  the  bifurcation  of  the  trachea,  and  in  the  region  of 
the  hiatus. 

Symptoms.  Difficulty  in  swallowing  is  present  in  all  cases  of  stricture  of 
the  esophagus.  The  degree  of  dysphagia  depends  upon  the  degree  of  stenosis. 
In  cases  of  cicatricial  stenosis  the  narrowing  usually  develops  slowly,  and 
the  dysphagia  comes  on  gradually.  At  first  the  patient  experiences  difficulty 
in  swallowing  solid  food,  especially  meat.  Early  in  the  disease  there  is  usually 
a  sense  of  pain  or  discomfort  in  the  esophagus  at  the  point  of  the  stricture, 
especially  during  the  act  of  swallowing.  Occasionallv  the  patients  locate  the 
stricture  incorrectly,  as  the  pain  may  be  referred  to  the  region  of  the  sternum 
and  circoid  cartilage  when  the  obstruction  is  in  the  lower  portion  of  the  canal. 

As  the  stenosis  increases  the  difficulty  in  swallowing  becomes  more  marked, 
and  the  patient  soon  develops  a  rather  characteristic  symptom  of  being  careful 
to  take  only  a  small  amount  of  food  at  a  time,  and  then  swallowing  slowly. 
They  frequently  gag,  and  then  carry  out  certain  motions  with  the  head.  There 
is  frequently  regurgitation  of  food ;  if  the  obstruction  is  high  up  this  takes 
place  immediately,  if  lower  down,  a  short  time  may  intervene  before  the 
regurgitation  occurs. 

Where  the  obstruction  is  very  marked  mucous  and  swallowed  saliva  accu- 
mulate, constituting  a  great  annoyance  to  the  patient  by  being  frequently 
regurgitated  into  the  mouth.  As  soon  as  the  obstruction  is  pronounced,  loss 
of  weight  takes  place  from  lack  of  sufficient  nourishment. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


421 


Dilatation  of  Stricture  of  Esophagus. 

(a)  Shows  continuous 'double  thread  of  heavy  braided  silk  passed  through  mouth,  pharynx, 
esophagus,  stomach,  gastrostomy  wound,  and  from  this  to  the  mouth,  a  rubber  drainage  tube 
being  drawn  through  the  loop  in  the  string  for  the  purpose  of  dilating  the  stricture,  and  a 
second  diainage  tube  being  drawn  through  the  loop  made  by  the  first. 

For  the  dilatation  of  a  stricture  in  the  lower  end  of  the  esophagus  it  has  been  suggested 
that  the  stomach  be  opened  after  the  method  just  described  and  that  then  a  dilator  formed 
after  the  pattern  of  a  glove-stretcher  be  passed  through  the  stricture  from  below  and  the 
latter  \gtj  thoroughly  and  repeatedly  dilated;  great  care  being  taken  however  not  to  tear, 
but  simply  to  stretch  the  tissues,  which  can  be  accomplished  only  if  the  dilatation  is  made 
very  slowly  and  is  very  frequently  repeated. 

(b)  The  same  as  (a),  a  larger  double  rubber  drainage  tube  having  been  drawn  through 
the  loop  in  the  first  and  left  in  the  stricture  temporarily  for  the  purpose  of  dilating  the  latter. 

The  number  and  the  size  of  these  tubes  may  be  increased  until  the  desired  degree  of 
dilatation  has  been  accomplished.  It  is  important  that  they  should  be  left  in  place  in  the 
stricture  for  several  minutes  after  they  have  been  drawn  into  this  in  order  to  secure  the  dilata- 
tion which  comes  from  the  elasticity  of  the  rubber  tubing. 


422  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Diagnosis.  In  mechanical  stricture  of  the  esophagus  there  is  present  a 
series  of  symptoms  which  are  self-evident ;  of  these  the  dysphagia  and  regurgi- 
tation of  food  are  the  most  prominent.  When  a  patient  complains  of  difficulty 
in  swallowing,  or  of  vomiting  at  the  time  of  eating,  we  should  put  him  to  the 
test  and  observe  what  happens  during  the  ingestion  of  food  and  drink.  Even 
though  the  obstruction  has  existed  but  a  short  time,  we  will  observe  that  the 
patient  has  learned  to  eat  slowly,  to  take  only  small  bites  of  food  and  to 
masticate  very  carefully.  If  the  stenosis  is  very  marked  even  liquids  will  be 
taken  slowly  and  it  wdll  be  evident  that  it  is  an  effort  to  cause  the  food  to  go 
down.  If  the  patient  is  urged  to  eat  more  rapidly  he  will  say  that  it  is  im- 
possible. If  eating  is  forced  there  will  be  a  regurgitation  of  food  usually 
mixed  with  mucus.  This  takes  place  without  any  effort  on  the  part  of  the 
patient  and  is  very  different  from  the  expulsive  evidences  which  accompany 
ordinary  vomiting.  The  patient  can  practically-  always  distinguish  the  dif- 
ference between  the  act  of  vomiting  and  that  of  regurgitation  of  food. 

If  the  history  indicates  the  presence  of  a  stenosis  we  can  confirm  the 
diagnosis  b}'  passing  a  stomach  tube  or  bougie.  Before  such  instruments  are 
used  a  careful  examination  should  be  made  to  determine  if  there  is  any 
contraindication  to  their  passage. 

The  presence  of  an  aneur3'sm  or  high  grade  arterio-sclerosis  or  pronounced 
heart  incompetency  render  the  procedure  unsafe. 

As  a  rule  it  is  best  to  pass  a  soft  stomach  tube  first,  but  the  exact  location 
and  degree  of  obstruction  may  be  more  accurately  determined  by  using  bougies 
with  olive  tips. 

The  diagnosis  and  location  of  an  esophageal  stenosis  are  usually  easy,  but 
to  determine  the  exact  nature  of  the  obstruction  is  often  a  difficult  matter. 
In  adults  carcinoma  is  by  far  the  most  common  cause  of  stricture.  It  is  char- 
acterized by  the  symptoms  described  above,  its  onset  is  usually  gradual, 
although  the  inability  to  swallow  solids  may  come  on  suddenh".  The  course 
of  carcinoma  is  progressive,  there  is  a  gradual  loss  of  weight  and  later 
cachexia.  Metastatic  growths  should  ahvays  be  looked  for,  although  they  are 
rarely  of  value  in  the  early  diagnosis.  As  there  is  a  tendency  toward  early 
ulceration  in  carcinoma  the  presence  of  blood  in  the  stools  is  an  important 
diagnostic  sign.  In  carcinoma  the  passage  of  even  a  soft  stomach  tube  usually 
causes  bleeding  on  account  of  its  ulcerating  surface. 

In  cicatricial  stenosis  there  will  be  a  gradual  and  persistent  obstruction 
with  the  absence  of  the  above  symptoms.  There  is  usually  a  history  of  swal- 
lowing caustic  acids  or  alkalies.  This  history,  together  with  the  presence  of  a 
firm  obstruction,  as  determined  by  passing  a  bougie,  will  usually  suffice  to 
make  tlie  diagnosis  of  cicatricial  stenosis. 

Use  of  X-ray.  The  exact  location  of  an  obstruction  of  the  esophagus  can 
usually  be  determined  by  the  X-ray,  which  at  the  same  time  may  reveal  the 
nature  of  the  obstruction.  Frequently  a  better  understanding  of  the  condition 
can  be  determined  by  fluoroscoping  the  patient  than  by  taking  an  X-ray  photo- 
graph. The  patient  is  placed  behind  the  X-ray  screen  in  the  standing  position, 
and  is  then  asked  to  swallow  a  glass  or  two  of  buttermilk  and  bismuth.  As 
the  patient  swallows,  its  passage  along  the  esophagus  can  be  noted.  After  a 
careful  observation  of  the  course  of  the  esophagus  has  been  made  with  the 
screen  the  X-ray  photograph  is  taken. 

Treatment.  Much  can  be  done  to  prevent  the  formation  of  troublesome 
strictures  following  traumatisms  of  the  esophagus  by  treating  the  condition 
before  contraction  takes  place.  After  the  swallowing  of  caustic  substances, 
systematic  sounding  should  be  instituted  in  from  two  to  four  weeks.  Foreign 
bodies  should  not  be  allowed  to  remain  in  the  esophagus  until  ulceration  has 
taken  place. 


Dilatation  of  Stricture  of  Esophagus. 

re)  Barnes'  dilator  introduced  after  a  partial  dilatation  has  been  accomplished  by  the 
methods  illustrated  in  Figs.  A  and  B.  The  stop-cock  enables  the  surgeon  to  distend  the  bag 
and  to  keep  it  distended  for  any  desired  time  while  engaged  m  the  stricture  .    ,    -        , 

(d)     Barnes'   uterine   dilator   in  position;    (s)    shows  the   stop-cock,   which   maintains   a 

constant   degree   of   dilatation.  ,  .     ,.  .,    .   ■  -4.     +v,„  ,.^;.-,f 

When  the  obstruction  is  at  the  point  indicated  ni  this  hgure,  that  f  opposite  the  point 
at  which  the  esophagus  passes  through  the  diaphragm,  it  has  been  ^^gge^ted  that  the  stricture 
may  be  due  to  circular  constriction  of  the  muscles  of  the  diaphragm  surrounding  the  esophagus 
and  in  one  case  at  least  the  careful  division  of  these  muscle  bands  has  resulted  m  a  cure  of 
the  stricture. 


424      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Dilatable  strictures.  Gradual  dilatation  is  the  operation  of  choice  in  these 
cases.  If  the  stricture  is  not  too  tight  the  woven  flexible  bougies  are  suitable 
for  this  purpose.  The  bougie  is  lubricated  with  vaseline,  olive  oil,  or  glycerine 
and  passed  after  the  method  described  in  the  part  upon  examination  of  the 
esophagus.  In  the  tighter  strictures  a  bougie  with  a  whalebone  stem,  to  which 
may  be  attached  increasing  sizes  of  ivory,  olive-shaped  tips,  will  be  found  most 
valuable.  The  tip  should  be  made  long  and  tapering  so  that  it  will  enter  the 
stricture  with  more  ease  than  the  ordinary  olive  tip.  There  are  many  cases 
in  which  the  woven  flexible  bougie  or  the  olive  tips  cannot  be  passed  and  the 
surgeon  is  apt  to  pronounce  the  case  one  of  impermeable  stricture.  However, 
in  these  cases  with  care  and  gentleness  a  filiform  bougie  can  easily  be  passed, 
even  though  several  sittings  are  required.  In  such  cases  several  small  hliform 
bougies,  on  one  end  of  which  threads  are  cut  so  as  to  be  attached  to  a  flexible 
dilator,  as  shown  in  the  plate,  should  be  inserted  into  the  esophagus  against 
the  stricture  in  the  same  manner  as  filiforms  are  inserted  into  the  urethra. 
Now  by  manipulating  first  one  bougie  and  then  another,  one  will  usually  slip 
through.  The  tapering  flexible  bougie  is  now  attached  to  the  filiform  which 
serves  as  a  guide  while  the  bougie  is  pushed  on  through  the  stricture.  After 
the  filiform  has  been  passed  a  few  times,  the  passage  of  the  woven  flexible 
bougie  or  the  olive  tips  can  probably  be  accomplished.  These  should  be  passed 
in  increasing  sizes  at  intervals  two  or  three  times  a  w^eek.  After  a  few  days, 
when  the  patient  has  become  accustomed  to  this  procedure,  the  largest  flexible 
bougie  passed  should  be  left  in  place  for  a  period  of  five  to  fifteen  minutes. 

Many  months  are  usually  required  for  thorough  dilatation  of  one  of  these 
strictures,  and  after  the  patient  is  apparently  cured,  sounds  should  be  passed 
occasionally  for  several  years. 

Non-dilatable  strictures.  In  strictures  which  are  impermeable  from  above, 
or  cannot  be  successfully  treated  by  dilatation  through  the  mouth,  the  treat- 
ment depends  upon  the  condition  of  the  patient  and  upon  the  location  of  the 
stricture.  If  the  patient  is  in  an  exhausted  state  from  prolonged  starvation, 
a  temporary  gastrostomy  should  be  performed,  and  the  patient  nourished  in 
this  way  until  his  general  condition  has  improved.  By  this  means  rest  is  given 
to  the  aft'ected  parts  and  later  on  it  may  be  possible  to  dilate  the  stricture 
from  above,  and  if  not,  some  form  of  retrograde  dilatation  may  be  used. 

The  most  common,  as  well  as  the  most  serious,  strictures  are  those  at  the 
lower  end  of  the  esophagus.  The  best  method  of  dealing  with  these  is  some 
form  of  retrograde  dilatation. 

Esophageal  strictures  which  are  impermeable  from  above,  will  almost  in- 
variably permit  the  passage  of  a  bougie  from  below,  because  the  pressure  of 
the  food  in  trying  to  pass  down  the  esophagus  renders  the  canal  basin-shaped, 
while  on  the  distal  side  it  is  funnel  shaped,  thus  naturally  a  bougie  will  pass 
more  readily  upwards  through  the  stricture. 

The  Ochsner  method.  The  same  incision  is  made  as  used  in  ordinary  gas- 
trostomy. The  stomach  wall  is  brought  out  of  the  wound  and  a  purse-string 
suture  applied  to  describe  a  circle  one  and  one-half  inches  in  diameter.  An 
incision  is  made  in  the  stomach  wall  large  enough  to  admit  one  finger.  A 
filiform  bougie  is  now  passed  through  the  stricture  either  from  above  or  in  a 
retrograde  manner.  A  silk  cord  is  attached  to  the  end  of  the  bougie  and 
pulled  up  through  the  esophagus  and  out  through  the  mouth.  A  stronger  silk 
cord  is  attached  to  this  one  and  in  turn  is  drawn  through  downwards.  This 
performance  is  repeated  until  a  very  powerful  silk  cord  has  been  drawn 
through  double  and  tied  upon  itself,  as  shown.  The  feeding  tube  is  fastened 
in  the  stomach  by  tying  the  purse-string.    The  silk  cord  is  left  in  place,  passing 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      425 

around  through  the  esophagus  and  stomach  and  out  alongside  the  feeding 
tube,  so  that  it  cannot  be  dislodged  by  an  accidental  manipulation.  The  opera- 
tion is  then  completed  by  suturing  the  stomach  to  the  peritoneum  and  trans- 
versalis  fascia. 

The  feeding  tube  is  left  in  place  for  a  few  days  while  the  stomach  is  becom- 
ing thoroughly  attached  to  the  abdominal  wall,  during  which  time  the  patient 
receives  an  abundance  of  nourishing  food. 

The  dilatation  is  now  begun  in  the  following  manner;  by  means  of  the 
continuous  double  cord  another  cord  is  carried  through  the  stomach  into  the 
esophagus  and  out  through  the  mouth.  This  cord  should  again  be  double  so 
that  a  rubber  drainage  tube  may  be  looped  into  it  and  drawn  through  the 
stricture,  as  shown.  In  this  figure,  however,  the  rubber  tube  is  looped  directly 
upon  the  original  silk  cord,  which  is  not  a  safe  practice,  because  in  case  the 
cord  should  break  it  might  be  difficult  to  replace  it,  while  there  is  no  danger 
of  its  breaking  in  simply  carrying  through  another  cord. 

The  rubber  will  stretch  out  into  a  thin  body  when  drawn  through  a  tight 
stricture,  but  when  relaxed  will  act  as  a  powerful  dilator.  The  size  of  the 
rubber  tube  may  be  increased,  or  any  desired  number  may  be  drawn  through 
the  stricture  at  the  same  time,  as  the  calibre  of  the  latter  increases.  The 
rubber  tubes  may  be  drawn  back  and  forth,  the  first  one  is  drawn  through 
the  mouth  and  out  of  the  opening  in  the  stomach  by  means  of  the  silk  cord. 
The  dilatation  can  now  be  carried  on  by  looping  a  larger  rubber  tube  through 
the  loop  of  the  other  tube  and  by  means  of  the  latter  draw  the  larger  tube  up 
through  and  out  of  the  mouth,  and  then  repeat  this  until  as  large  a  tube  as 
desired  is  drawn  through  the  stricture.  This,  however,  requires  a  large  open- 
ing in  the  stomach,  which  is  not  necessary  if  the  tubes  are  simply  looped  into 
the  silk  cord  and  by  alternating  the  direction  of  the  pull  the  tube  is  drawn 
out  by  its  free  ends  and  in  by  the  silk  loop.  Later  on,  a  Barnes  dilator  in  a 
collapsed  condition  may  be  drawn  into  the  stricture.  In  this  plate  the  dilator 
was  drawn  up  from  below,  but  it  can  be  drawn  down  from  above  with  no 
more  difficulty.  The  fact  that  the  dilator  is  engaged  in  the  stricture  can  be 
recognized  by  the  difficulty  one  experiences  in  drawing  it  into  the  narrow 
opening,  and  the  shoulders  upon  the  bag  create  a  tendency  to  keep  it  from 
slipping  beyond  the  stricture. 

When  once  in  place  the  Barnes'  dilator  may  be  inflated  with  air  by  means 
of  a  rubber  bulb.  The  patient's  own  feelings  must  serve  as  a  guide  to  the 
degree  of  dilatation  it  is  safe  to  make  use  of  at  any  given  time,  and  the  length 
of  time  it  is  wise  to  leave  the  dilator  in  place. 

Sippy  has  constructed  a  dilator  superior  to  the  Barnes,  which  can  be  used 
in  the  same  manner.  This  consists  of  a  rubber  bag,  about  three  and  one-half 
inches  long,  encased  in  a  silk  bag,  which  limits  accurately  the  distension  pro- 
duced. When  inflated  with  air  the  circumference  of  the  silk  bag  is  about 
15  cm.  The  dilating  force  is  accurately  controlled  by  the  silk  bag,  and  the 
maximum  pressure  exerted  at  the  point  desired.  The  silk  bag  is  covered  with 
a  rubber  bag  to  prevent  friction. 

If  simple  dilation,  either  by  the  use  of  the  rubber  tubes  or  the  Barnes 
dilator,  does  not  expand  the  stricture  rapidly  enough,  the  edges  of  the  stricture 
may  be  rendered  tense  either  by  drawing  a  number  of  rubber  tubes  into  the 
stricture  or  by  the  inflated  bag,  and  then  using  the  silk  cord  after  the  fashion 
of  a  chain  saw,  similar  to  the  method  of  Abbe,  thus  cutting  the  edges  of  the 
stricture. 

After  a  considerable  degree  of  dilatation  has  been  accomplished  it  is  well 


426  SURGERY  OF  THE  ESOPHAGUS  AND  ST0:MACH 

to  attempt  the  passage  of  esophageal  bougies  from  above.  These  should  be 
passed  every  day  at  first,  then  once  a  week  for  several  months  and  then  once 
a  month  for  many  years.  The  patient  may  be  taught  to  pass  the  bougies 
himself  and  then  to  report  personally  to  the  surgeon  occasionally,  because  he 
often  imagines  that  he  has  succeeded  in  passing  a  bougie  when  he  has  only 
introduced  it  down  to  the  stricture. 

After  removing  the  feeding  tube  in  these  cases  in  which  an  adequate 
passage  through  the  esophageal  stricture  has  been  established  by  dilatation, 
the  opening  in  the  stomach  will  usually  close  spontaneously. 

Abbe's  string  cutting  method.  The  abdomen  is  opened  and  the  anterior 
wall  of  the  dome  of  the  stomach  is  brought  up  and  sutured  to  the  edges  of  the 
abdominal  wall.  An  opening  is  made  in  the  stomach  and  two  fingers  are 
inserted  into  the  viscus  and  passed  along  its  anterior  wall  to  locate  the  opening 
of  the  esophagus. 

Abbe  (Med.  Bee,  Nov.  20,  1907;  calls  attention  to  the  fact  that  it  is  often 
difficult  to  locate  the  esophageal  opening.  In  connection  with  this  Abbe  states : 
'"This  has  been  interesting  to  me  from  a  physiological  point  of  view.  We 
ordinarily  think  of  the  stomach  as  pictured  in  anatomy,  showing  a  funnel- 
shaped  expansion  of  the  esophagus  where  it  joins  the  stomach  wall.  It  has 
never  been  my  experience  to  find  this  condition  in  the  living  stomach.  As  the 
finger  passes  back  and  forth  over  its  upper  interior  aspect,  one  feels  an  even 
surface  more  like  the  interior  of  any  dome-shaped  cavity.  This  surface  is 
maintained  by  the  circular  sphincteric  muscle  layers,  and  it  is  not  until  a 
moment's  pressure  of  the  finger  at  the  right  place  causes  them  to  yield  that  it 
slips  upward  into  the  esophagus. 

"I  have  never  seen  this  point  stated  in  surgical  works,  and  it  has  inter- 
ested me  as  representing  an  always  present  physiological  condition  which 
prevents  food  regurgitation." 

AYlien  the  esophageal  opening  has  been  located,  a  long  filiform  whale-bone 
bougie  guided  by  the  index  finger  is  passed  up  along  the  esophagus  from  the 
stomach  to  the  mouth.  To  the  end  of  this  a  heavy  silk  string  is  tied  and  pulled 
up  through  and  out  the  mouth.  A  tapering  bougie  is  now  passed  up  along 
the  string  and  through  the  stricture  until  it  becomes  wedged  tight  in  the 
strictured  portion.  The  string  is  now  pulled  backwards  and  forwards  like  a 
saw,  thus  cutting  the  tight  stricture  band.  As  the  stricture  gives  way,  the 
bougie  is  passed  farther  up  until  it  again  becomes  tight  and  the  string  sawing 
is  repeated  until  a  large  bougie  can  be  passed  from  the  stomach  to  the  mouth. 
In  place  of  passing  the  bougie  up  along  the  string,  as  described  above,  a  second 
string  may  be  drawn  through  the  esophagus  to  the  lower  end  of  which  a  Bill- 
roth dilating  bougie  is  tied,  and  by  means  of  this  string  the  bougie  is  drawn 
upwards  until  it  becomes  tightly  engaged  in  the  stricture  and  then  the  sawing 
process  used  as  above. 

The  fundamental  principle  of  this  operation  is,  that  the  dilator  must  be 
pressed  tightly  into  the  stricture  in  order  that  the  string  moving  to  and  fro 
may  eat  its  way  through  the  stricture.  No  tissue  will  be  affected  by  the  string, 
except  where  it  is  on  the  stretch. 

The  gastrostomy  opening  may  be  closed  immediately  after  the  cutting 
process  is  completed,  or  it  may  be  left  open  for  a  few  days  mitil  it  is  demon- 
strated that  a  large-sized  bougie  can  be  readily  passed  from  above.  Bougies 
should  be  passed  every  other  day  at  first,  then  weekly,  then  once  a  month  for 
a  year  and  after  that  once  each  year. 

Billroth 's  method.  A  filiform  bougie  is  passed  into  a  gastrostomy  opening 
and  up  through  the  stricture  to  the  mouth,  or  out  through  an  external  esopha- 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  427 

gotomy  opening,  and  a  strong  thread  drawn  down  through  and  out  of  the 
gastric  opening.  Then  to  the  lower  end  are  fastened  in  succession  conical 
bougies  whose  tips  are  capped  by  a  metal  point  into  which  the  string  is  tied. 
From  the  smallest  to  the  largest  ones  they  are  thus  safely  drawn  up  through 
the  stricture,  with  no  danger  of  perforating  the  wall  of  the  esophagus. 

In  performing  an}'  of  the  retrograde  methods  of  dilatation  one  is  apt  to 
have  difficulty  in  passing  the  first  string  through  the  stricture.  It  may  not 
only  be  impossible  to  pass  a  bougie  from  above,  but  one  may  also  experience 
great  difficulty  in  finding  the  cardiac  opening.  In  such  cases  a  silk  thread 
2uay  be  fioated  through  from  above,  as  advocated  by  Dunham.  This  is 
accomplished  by  having  the  patient  swallow  a  silk  thread  down  to  the  stricture. 
The  patient  is  now  given  a  swallow  of  water.  As  this  trickles  down  through 
the  stricture  it  may  carry  the  thread  through  with  it,  and  then  the  thread  can 
be  fished  out  through  the  gastric  fistula. 

DIVERTICULA  OF  THE  ESOPHAGUS 

Diverticula  of  the  esophagus  are  pouch-like  sacculations  of  a  portion  of 
the  circumference  of  the  tube.  The  characteristic  features  of  a  true  diver- 
ticulum are  sharply-defined,  pouch-like  protrusions  of  the  esophageal  wall, 
lined  with  mucous  membrane. 

The  symptoms  vary  according  to  the  location  of  the  diverticulum.  If  it  is 
situated  in  the  cervical  portion  the  early  symptoms  may  be  only  slight,  such  as 
dryness  and  irritation  about  the  throat.  Later  the  sensation  of  a  foreign  body 
may  be  present.  As  the  sacculation  becomes  larger,  the  food  accumulated 
therein  crowds  against  the  esophagus  and  obstructs  its  lumen,  causing  diffi- 
culty in  swallowing  and  regurgitation  of  food.  In  about  one-third  of  the  cases 
a  tumor  can  be  discovered  in  one  side  of  the  neck  after  eating. 

The  majority  of  the  patients  learn  that  by  holding  the  head  in  a  certain 
position  they  may  be  able  to  swallow;  others  learn  to  empty  the  sac  by  making 
pressure  upon  it  with  the  hand.  It  frequently  requires  hours  for  a  meal.  In 
some  cases  a  peculiar  gurgling  sound  is  heard  during  the  act  of  swallowing. 
In  most  cases  there  is  a  constant  retention  of  particles  of  food  in  the  sac,  caus- 
ing a  fetor  which  may  become  intolerable.  It  is  often  noticed  that  the  patient 
can  swallow  better  during  the  early  part  of  the  meal.  As  the  sac  fills,  it  crowds 
upon  the  esophagus  and  obstructs  its  lumen. 

Diagnosis.  The  diagnosis  can  usually  be  made  from  the  above  symptoms. 
The  historj^  of  the  gradual  development  of  these  disturbances  and  the  regur- 
gitation of  unaltered  food  should  always  arouse  suspicion  of  a  diverticulum. 
If  a  tumor  develops  in  the  neck  during  a  meal  and  can  be  emptied  by  pressure, 
it  is  still  more  probable  that  a  diverticulum  is  present.  If  a  bougie  is  passed, 
it  is  usually  arrested  at  a  point  near  the  cricoid  cartilage.  If  the  bougie-  is 
slightly  withdrawn  and  the  direction  of  its  point  changed,  it  may  pass  on  into 
the  stomach.  It  frequently  happens  that  a  bougie  may  pass  readily  one  day 
and  not  the  next.  Occasionally  when  a  bougie  has  been  introduced  into  the 
diverticulum  a  second  bougie  may  at  the  same  time  be  passed  on  into  the 
stomach.  This  would  be  impossible  if  there  was  a  stenosis.  Bismuth  sus- 
pended in  oatmeal  gruel  may  be  administered  and  an  X-ray  picture  taken. 
If  the  sacculation  is  sufficient  the  picture  will  show  the  location  and  approxi- 
mate size. 

The  sj-mptoms  of  the  deep-seated  diverticula  are  vomiting  or  regurgita- 
tion of  food  during  or  soon  after  the  meal.  After  vomiting  the  patients  are 
again  able  to  eat  for  awhile.    Occasionally  it  is  found  that  after  eating  a  small 


428  SURGERY  OF  THE  ESOPHAGUS  AND  STOIMACH 

quantity  of  food  there  is  a  sense  of  weight  or  pressure  in  the  region  of  the 
sternum.  These  disturbances  gradually  increase  and  larger  quantities  of  food 
are  vomited  and  less  food  enters  the  stomach,  so  that  the  patient  gradually 
becomes  emaciated. 

The  diagnosis  is  based  upon  the  clinical  history  and  examination  with 
bougies.  For  this  purpose  a  bougie  with  a  curved  tip,  like  a  Mercier  catheter, 
is  most  convenient.  With  these  bougies  it  is  usually-  easy  to  pass  by  the 
diverticulum  or  by  turning  the  point  pass  into  the  sacculation,  and  also  deter- 
mine whether  the  diverticulum  is  situated  to  the  right  or  the  left.  A  bismuth 
mixture  may  be  administered  and  an  X-ray  photograph  taken  for  the  purpose 
of  determining  the  size  and  location. 

Treatment.  The  treatment  of  esophageal  diverticula  in  the  cervical  region 
may  be  non-operative  or  surgical.  The  non-operative  consists  in  the  persistent 
use  of  sounds  and  stomach  tubes.  Permanent  benefit  to  the  patient  can  rarely 
be  expected  by  this  method. 

The  surgical  treatment  may  be  palliative  or  radical.  The  palliative  treat- 
ment consists  in  performing  a  gastrostomy  to  secure  a  means  of  administering 
food.  When  the  patient  is  in  a  bad  general  condition,  it  may  be  advisable  to 
perform  a  temporary  gastrostomy  in  order  to  be  able  to  improve  his  general 
condition  preparatory  to  the  radical  operation. 

This  also  affords  a  method  of  administering  food  other  than  by  the  mouth, 
until  the  wound  in  the  esophagus  has  healed. 

Extirpation  of  the  sac.  as  first  suggested  by  Kluge,  is  considered  the  best 
method  for  the  permanent  cure  of  this  condition.  The  chief  danger  of  the 
operation  seems  to  be  from  infection,  which  may  occur  from  the  contents  of 
the  sac  during  its  removal,  or  from  leakage  from  the  esophageal  wound  after 
it  has  been  sutured. 

The  technique  of  the  operation  is  as  follows :  An  incision  is  made  along 
the  anterior  border  of  the  sterno-cleido-mastoid  muscle  from  the  level  of  the 
hyoid  bone  to  the  clavicle.  The  esophagus  is  reached  by  means  of  blunt  dis- 
section. No  vessels  of  any  importance  are  encoimtered  except  the  superior 
thyroid  and  occasionally  the  inferior  thyroid.  Either  one  or  both  of  these 
may  be  ligated.  The  thyroid  gland  can  be  drawn  to  one  side  and  if  not 
enlarged  will  not  be  in  the  way.  The  sac  when  located  should  be  carefully 
enucleated  like  that  of  a*  hernia.  The  most  important  step  in  the  operation  is 
the  closing  of  the  esophagus  after  removal  of  the  diverticulum.  Probably  the 
best  method  is  that  similar  to  an  intestinal  suture  in  separate  layers,  first 
the  mucosa,  then  muscular  coat  and  finally  the  adventitia,  using  catgut  for  the 
first  two  layers  and  silk  for  the  last  suture. 

It  is  advisable  to  drain  the  wound  bj'  carrying  a  piece  of  iodoform  gauze 
or  cigarette  drain  from  the  esophageal  suture  out  through  the  skin  incision. 

The  treatment  of  epibranchial  diverticula  and  those  located  just  above 
the  diaphragm  is  unsatisfactory.  Irrigation  with  mild  antiseptic  solution  will 
prevent  irritation  and  ulceration  of  the  mucous  membranes.  These  irrigations 
and  the  passage  of  bougies  often  atford  considerable  relief. 

IDIOPATHIC  DILATATION  OF  THE  ESOPHAGUS 

By  idiopathic  dilatation  of  the  esophagus  is  meant  a  dilatation  with  no 
ascertainable  organic  cause.  The  esophagus  usually  becomes  dilated  throusrh- 
out  a  large  portion  of  its  extent,  sometimes  involving  practically  its  entire 
length  in  a  spindle-shaped  or  cylindrical  manner.  Our  lack  of  knowledge 
of  the  etiology  of  this  condition  is  indicated  by  the  variety  of  names  under 


I 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


429 


which  the  cases  have  been  reported,  such  as  cardiospasm,  idopathic,  fusiform, 
diffuse  dilatation  and  dilatation  without  anatomical  stenosis.  Clinically,  as 
far  as  we  can  judge  from  the  history  of  these  cases,  a  definite  spasm  of  the 
cardia  seems  to  be  one  of  the  earliest  manifestations  of  the  disease. 

Etiology.  The  cause  of  the  spasm  is  a  matter  of  speculation.  In  the  ma- 
jority of  the  cases  a  definite  etiological  factor  cannot  be  found.  A  few  cases 
have  been  reported  associated  with  gross  lesions  of  the  esophagus  such  as 
ulcers,  fissures,  carcinoma  of  the  cardia  and  of  the  stomach.  Plummer  has 
found  three  cases  of  carcinoma  complicated  by  cardiospasm  and  one  case  of 
hourglass  stomach  due  to  syphilis  with  secondary  cardiospasm.  In  his  study 
of  forty  cases  of  cardiospasm  only  three  of  them  had  neurasthenic  symptoms, 
and  evidence  of  esophagitis  previous  to  the  onset  of  the  cardiospasm  could 
not  be  elicited  from  any  of  them. 

Symptoms.  Three  stages.  The  symptoms  of  cardiospasm  may  be  divided 
into  three  stages ;  first,  cardiospasm  with  some  difficulty  in  swallowing  but  no 
regurgitation  of  food;  second,  cardiospasm  with  immediate  regurgitation  of 
food ;  third,  cardiospasm  with  the  dilated  esophagus  with  retention  of  food  in 
its  dilated  portion  and  its  regurgitation  at  irregular  intervals. 


Plummer 's  Whalebone  Staff  with  Ivory  Tip  Drilled  and  Thread  Passing  Through  Same. 


In  the  majority  of  cases  the  first  attack  of  spasm  occurs  suddenly  while 
eating.  A  spasmodic  choking  sensation  is  experienced  at  some  point  along 
the  course  of  the  esophagus,  most  often  located  in  the  region  of  the  cardia. 
This  sensation  is  rarely  described  as  a  pain  and  may  be  referred  entirely  to 
the  epigastric  region  or  to  the  upper  portion  of  the  esophagus.  Sometimes 
the  spasm  is  described  as  a  delay  in  the  passage  of  food,  or  that  the  food 
''sticks"  beneath  the  sternum.  Soon  it  is  noticed  that  the  patient  eats  very 
slowly  and  finds  it  difficult  to  swallow.  It  may  be  necessary  to  wash  the  food 
down  with  water.  The  patient  may  go  through  certain  movements  of  the  body 
and  arms  or  take  deep  breaths  to  force  the  food  down. 

In  the  second  stage  the  patient  has  regurgitation  of  food  which  occurs 
immediately  after  swallowing.  During  the  early  portion  of  the  history  the 
attacks  occur  periodically,  but  with  varying  'degrees  of  intensity  and  with 
remissions  or  intermissions  covering  days,  weeks,  months  or  even  years.  The 
condition  pursues  its  slow  and  unmodified  course.  As  the  cardiospasm  be- 
comes more  complete,  the  regurgitation  of  food  and  secretions  of  the  esophagus 
come  on  more  frequently  and  more  regularly. 

In  the  third  stage  after  dilatation  takes  place  the  spasmodic  choking  sen- 
sation may  be  absent.  The  patient  is  able  to  take  the  first  portion  of  his  meal 
quite  comfortably,  but  the  food  is  retained  in  the  dilated  esophagus  instead 
of  passing  on  into  the  stomach.    After  the  sac  is  filled,  further  food  is  regurgi- 


430  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

tated  or  forces  some  of  the  preceding  portion  into  the  stomach.  Of  the  con- 
tents of  the  esophagus  at  the  close  of  a  meal,  the  more  fluid  portion  may 
gradually  slip  through  into  the  stomach.  The  solid  food  with  mucus  is  usually 
regurgitated  later  at  irregular  intervals.  Solid  food  like  meats  may  remain 
in  the  esophagus  several  days.  Plummer  states  that  the  sac  never  completely 
empties  itself  and  that  on  many  occasions  he  has  withdrawn  from  two  to 
sixteen  ounces  of  food  after  the  patient  has  fasted  for  twenty-four  to  thirty- 
six  hours.  The  regurgitation  is  often  looked  upon  as  vomiting  both  by  the 
patient  and  the  physician.  Some  patients  insist  that  the  food  enters  the 
stomach  but  will  not  stay,  while  others  state  that  it  lodges  beneath  the  sternum. 
They  practically  all  complain  of  a  sense  of  weight  and  discomfort  in  the  chest 
and  will  also  maintain  that  the  regurgitated  food  is  not  sour. 

Diagnosis.  The  diagnosis  of  cardiospasm  is  apt  to  be  difficult  in  the  begin- 
ning, especially  in  patients  who  might  be  supposed,  on  account  of  their  age, 
likely  to  suffer  from  carcinoma  of  the  cardia.  But  in  advanced  cases  the 
diagnosis  should  not  be  difficult.  Generally  the  diagnosis  can  be  premised 
from  the  history.  "Without  previous  warning  there  is  sudden  difficulty  in 
swallowing,  or  the  patient  unconsciously  gets  to  nibbling  and  following  each 
deglutition  of  solid  food  with  a  swallow  of  water.  At  first  liquids  are  often 
swallowed  with  greater  difficulty  than  solids.  After  dilatation  takes  place  the 
obstruction  is  present  alike  to  liquids  and  solids. 

An  important  diagnostic  feature  is  that  there  may  be  little  or  no  obstruc- 
tion to  the  passage  of  a  bougie  even  in  cases  in  which  a  large  quantity  of  food 
is  retained  in  the  esophagus.  In  the  average  case  when  a  sound  is  passed,  it 
will  be  temporarily  arrested  at  the  cardia  and  then  when  slight  pressure  is 
made  it  passes  on  into  the  stomach.  A  large  bougie  will  often  pass  as  easily 
as  a  small  one.  This  is  not  true  in  case  of  an  organic  stricture.  For  these 
cases  Plummer  has  devised  an  olive-tipped  bougie  passed  on  a  silk  thread  as 
a  guide. 

The  patient  slowly  swallows  six  yards  of  silk  thread.  This  passes  down 
through  a  sufficient  number  of  coils  of  intestine  to  prevent  its  withdrawal  on 
being  pulled  taut.  He  has  the  patient  swallow  three  yards  in  the  afternoon 
and  three  yards  on  the  following  morning.  In  this  manner  the  first  portion 
forms  a  snarl  in  the  esophagus  or  stomach,  which  passes  out  into  the  intestines 
during  the  night,  the  remaining  portion  passing  without  snarling.  The  olive 
tips  for  threading  on  this  string  are  drilled  from  the  tip  to  one  side  of  the 
base.  The  olive  tip  after  being  fastened  on  the  end  of  a  whale-bone  staff  is 
threaded  upon  the  silk  thread  protruding  from  the  mouth.  The  string  is  now 
pulled  taut  as  the  sound  is  passed  on  down  the  esophagus.  The  silk  thread 
as  a  guide  points  the  bougie  directly  into  the  cardiac  orifice  and  avoids  that 
resistance  encountered  in  sliding  the  olive  along  the  flaring  wall  of  the  esopha- 
gus or  the  straightening  out  of  some  fold  just  as  it  is  about  to  enter  the  cardia. 

The  character  of  the  resistance  met  with  at  the  cardia  is  of  the  utmost 
importance  in  the  differential  diagnosis  of  organic  and  spasmodic  stricture  of 
that  part. 

Excitement,  overwork  and  worry  are  factors  that  may  increase  the  spasm. 
The  patient  frequently  awakens  at  night  and  finds  food  upon  the  pillow  or 
finds  his  mouth  and  posterior  nares  filled  with  former  contents  of  the  esopha- 
gus. In  organic  stricture  the  retention  of  food  and  mucus  is  slight  in  com- 
parison to  what  it  may  be  from  the  result  of  cardiospasm.  X-ray  pictures  of 
the  dilated  esophagus  may  be  obtained  by  having  the  patient  swallow  bismuth 
subnitrate  suspended  in  oatmeal  gruel,  until  the  choking  sensation  occurs, 
then  the  part  is  photographed. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      431 

Treatment.  Forcible  dilatation  is  the  best  method  of  treating  cardiospasm. 
Until  recently  the  treatment  of  cardiospasm  has  consisted  in  such  ineffectual 
measures  as  looking  after  the  patient's  general  condition;  placing  him  under 
the  best  hygienic  care ;  restricting  the  diet  to  fluid,  non-irritating  substances ; 
effervescent  drinks ;  administering  sedatives ;  the  passing  of  large  bougies  and, 
as  a  last  resort,  performing  a  gastrostomy.  The  passage  of  bougies  has  been 
followed  by  good  results  in  some  cases,  but  if  there  is  much  dilatation  of  the 
esophagus  such  results  are  only  temporary.  It  is  impossible  to  actually  stretch 
the  orifice  by  passing  sounds,  because  one  cannot  pass  a  bougie  large  enough 
to  produce  actual  stretching  of  the  muscle  fibers. 

Sippy  dilation  method.  Other  means  have  been  devised  to  stretch  the 
cardia.  Sippy  has  constructed  a  dilator  consisting  of  a  rubber  bag  about  10 
cm.  long  encased  in  one  of  silk,  which  limits  the  distension  produced.  When 
inflated  the  circumference  is  about  15  cm.  With  this  bag  the  maximum  pres- 
sure is  exerted  at  the  desired  point.  The  silk  covering  is  encased  in  a  rubber 
cover  to  prevent  friction.  A  long  non-elastic  rubber  tube  is  attached  to  the 
bag  at  one  end  and  connected  with  an  air  pump  at  the  other.  It  is  essential 
to  measure  the  amount  of  pressure  within  the  bag  during  the  dilatation  and 
this  is  accomplished  by  connecting  a  column  of  mercury  to  the  tube  between  the 
bag  and  the  pump.  The  exact  distance  of  the  cardia  from  the  incisor  teeth  is 
measured  by  a  bougie.  The  bag  in  a  collapsed  condkion  is  carried  down  into 
the  cardia  by  means  of  a  whale-bone  staff.  The  dilatation  is  now  accomplished 
by  distending  the  bag  with  air.  The  cardia  will  stand  a  pressure  of  500  mm., 
but  Sippy  has  found  that  from  100  to  300  mm.  of  pressure  exerted  for  a  period 
of  three  minutes  will  be  sufficient  to  afford  relief  in  most  cases.  The  number 
of  dilatations  ranges  from  one  to  ten.  This  method  of  treatment  is  used 
without  anesthesia. 

The  immediate  results  from  this  treatment  are  most  striking.  Usually  the 
patient  is  able  to  take  most  any  kind  of  food  at  the  first  meal  following  the 
dilatation.  Sufficient  time  has  not  elapsed  since  the  introduction  of  this  pro- 
cedure to  formulate  definite  conclusions  as  to  the  ultimate  outcome.  In  forty 
cases  treated  by  Plummer,  twenty-nine  have  remained  well  and  in  several  of 
these  the  time  elapsed  since  the  dilatation  is  over  two  years.  In  the  eleven  cases 
in  which  the  symptoms  returned,  the  time  elapsed  after  the  treatment  varied 
from  three  to  seven  months.  There  has  been  no  recurrence  in  any  case  which 
remained  well  for  one  year. 

SURGERY  OF  THE  STOMACH 

General  considerations.  Stomach  surgery  at  the  present  time  is  instituted 
to  a  very  large  extent  for  the  purpose  of  overcoming  faulty  drainage  of  this 
organ.  In  various  ways  the  pylorus  may  become  obstructed,  so  that  the  con- 
tents of  the  stomach  cannot  pass  on  into  the  intestine  in  a  normal  way,  and  as 
a  result  there  is  first  a  compensatory  hypertrophy  of  the  walls,  then  a  dilatation 
with  an  accumulation  of  mucus  and  food  remnants  which  are  sure  to  undergo 
decomposition.  This  is  accompanied  by  the  formation  of  gas,  which  will 
further  increase  the  distension  of  the  stomach.  This  in  turn  produces  a  de- 
formity in  the  outlines  of  the  stomach,  the  latter  taking  the  form  of  a  pouch 
bending  downward,  which  increases  the  obstruction  to  the  pylorus,  because 
the  food  has  to  be  elevated  a  considerable  distance  before  it  reaches  the  exit. 

The  normal  stomach  extends  obliquely  across  the  abdominal  cavity,  the 
cardiac  end  being  much  higher  than  the  pyloric.  The  lesser  curvature  of  the 
stomach  extends  almost  vertically  downwards  for  the  first  two-thirds  of  it? 


432      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

extent,  slanting  only  very  slightly  toward  the  right,  beginning  at  the  point  of 
entrance  of  the  esophagus,  almost  the  entire  curve  being  confined  to  the  third 
nearest  the  pj^lorus.  The  greater  curvature  is  more  uniform  and  extends 
across  the  abdomen  at  an  average  angle  of  about  45°.  It  is  important  to  bear 
this  in  mind,  because  it  explains  to  a  great  extent  the  increase  in  the  obstruc- 
tion resulting  from  the  element  of  dilatation,  which  is  in  itself  the  result  of  an 
obstruction  to  the  pylorus.  It  further  explains  some  of  the  unsatisfactory 
results  which  are  apt  to  persist  after  the  primary  obstruction  of  the  pylorus 
has  been  relieved  by  a  plastic  operation  to  enlarge  this  orifice. 

The  pylorus  which  has  been  thus  enlarged  would  readily  permit  the  stomach 
contents  to  pass  if  the  stomach  still  had  its  normal  form  and  position,  but 
with  the  greater  curvature  forming  a  deep  pouch,  which  has  resulted  from 
the  obstruction,  the  emptying  of  this  organ  is  greatly  interfered  with,  even 
if  the  constriction  of  the  pylorus  no  longer  exists. 

The  principal  diseases  of  the  stomach  that  are  amenable  to  surgical  treat- 
ment are  carcinoma,  gastric  and  duodenal  ulcers  and  their  complications. 

Gastric  and  duodenal  ulcers  Avill  be  considered  together  because  the 
stomach  and  duodenum  belong  together  embryologically,  anatomically  and 
physiologically,  and  are  very  closely  related  pathologically. 

Embryologically  they  are  formed  from  the  foregut,  the  lowest  end  of  which 
is  marked  by  a  more  or  less  distinctly  developed  sphincter-like  arrangement 
of  the  circular  muscle  fibres  located  from  two  to  ten  centimeters  below  the 
entrance  of  the  common  duct  into  the  duodenum. 

Anatomically  they  are  separated  by  the  pyloric  sphincter,  which  makes 
itself  known  to  a  marked  extent  only  when  the  stomach  contains  food. 

Physiologically  both  the  stomach  and  the  duodenum  serve  the  purpose  of 
preparing  food  in  such  a  manner  that  it  can  be  readily  absorbed  during  its 
passage  through  the  remaining  portion  of  the  alimentary  canal.  There  is  but 
very  little  absorption  of  food  as  it  passes  through  these  cavities. 

Functions  of  the  stomach.  The  stomach  has  five  clearly  defined  functions, 
which  must  be  borne  in  mind  in  the  surgical  treatment  of  this  organ. 

1.  It  stores  the  food  taken  at  one  meal. 

2.  It  secretes  the  digestive  ferments  which  act  in  an  acid  medium  which 
it  also  supplies  in  the  form  of  free  hydrochloric  acid. 

3.  It  acts  as  a  mixing  machine  which  saturates  the  food  with  the  digestive 
ferments  and  hydrochloric  acid. 

4.  It  grinds  the  food  into  the  proper  consistency  for  the  next  step  in  the 
course  of  digestion. 

5.  To  a  very  slight  extent  it  absorbs  some  of  its  contents. 

The  duodenum  serves  simply  as  an  extension  of  the  stomach  in  which 
small  portions  of  the  food  are  again  sub.jected  to  a  mixing  process,  this  time 
with  the  alkaline  bile  and  pancreatic  juice. 

In  the  treatment  of  gastric  and  duodenal  ulcers,  it  is  of  the  greatest  im- 
portance constantly  to  bear  in  mind  these  anatomical  and  physiological  facts, 
l3ecause  it  is  plain  that  every  surgical  interference  must  in  a  measure  disturb 
the  normal  anatomical  conditions,  and  this  in  turn  must  result  in  physiological 
changes  which  are  abnormal.  Primarily  gastric  surgery  deals  with  the  relief 
of  obstruction  of  the  pylorus  which  is  in  some  way  secondary  to  gastric  ulcer. 

Etiology  of  gastric  ulcer.  It  has  been  accepted  by  those  who  have  had  the 
greatest  amount  of  experience  in  the  treatment  of  gastric  ulcer  that  trau- 
matism from  within  is  the  chief  exciting  cause. 

A  vast  majority  of  these  ulceus  occur  in  the  pyloric  end  of  the  stomach 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


433 


Gastric  Ulcee.. 

Typical  chronic  gastric  ulcer  produced  artificially  by  Friedman  and  Hamburger  {Journal 
A.  M.  A.,  Aug.  1,  1914),  by  means  of  injecting  0.5  to  1  cc.  of  a  5  per  cent  acpeous  solution 
of  nitrate  of  silver  into  the  gastric  subniucosa  at  various  points,  causing  necrosis  of  the 
mucous  lining. 


Gastric  Ulcer. 

Chronic  ulcer  resulted  only  in  the  pyloric  end  of  the  stomach  because  this  location  is  the 
only  part  of  the  stomach  containing  the  three  essential  etiologic  elements:  "first,  a  local 
destruction  of  the  mucosa;  second,  an  active  or  over-active  gastric  juice,  and  third,  prolonged 
or  vigorous  contact  of  the  t^vo ' '  by  causing  hyperperistalsis. 


434      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

which  acts  more  pronouncedly  as  the  grinding  machine  and  is  consequently 
much  more  exposed  to  trauma  than  other  portions  of  the  organ. 

Many  clinicians  and  pathologists  have  attributed  gastric  ulcer  to  the  pres- 
ence of  thrombosis  or  embolism.  Attention  has  recently  been  directed  to  this 
etiologic  factor  again  by  the  excellent  work  of  Prof.  Paj^r  {Archiv.  f.  Klin. 
Chir.^  Vol.  84),  in  which  he  reviews  all  of  the  experiments  which  have  been 
made  during  the  past  half  century  in  this  connection. 

Another  factor  which  has  been  under  discussion  for  some  time  is  the  theory 
concerning  the  presence  or  absence  of  certain  substances  in  the  blood  which 
make  the  mucous  membrane  immune  against  the  digestive  action  of  its  own 
secretions.  It  has  been  suggested  that  in  the  presence  of  these  bodies  a  trau- 
matism of  the  mucous  membrane  of  the  stomach  will  heal  Avhile  in  their  absence 
an  ulcer  will  result. 

This  seems  to  be  borne  out  by  animal  experiments,  those  of  Fibrich  and 
those  of  Futterer  being  especially  interesting.  The  latter  author  seems  to 
have  proved  experimentally  that  traumatism  of  the  mucous  membrane  of  the 
stomach  results  in  ulcer  only  in  the  presence  of  general  anemia,  and  that  by 
overcoming  this  anemia  by  treatment  these  ulcers  will  heal  spontaneously  and 
permanently.  So  long  as  there  is  no  recurrence  of  the  anemia  there  is  no 
recurrence  of  the  ulcer,  according  to  this  author. 

There  seems  to  be  no  doubt  that  duodenal  ulcer  is  due,  in  the  vast  majority 
of  cases,  either  to  an  extension  past  the  pyloric  sphincter  of  a  gastric  ulcer, 
forming  what  is  usually  known  as  the  saddle-shaped  ulcer  of  the  pylorus,  or 
it  may  be  formed  through  the  corrosive  effect  of  the  hyperacid  gastric  juice, 
thus  virtually  becoming  a  peptic  ulcer. 

Ulcers  of  the  duodenum  also  occur  as  a  result  of  severe  burns  of  the  skin 
and  from  thrombosis  of  the  vessels  supplying  the  duodenum. 

Frequency  of  occurrence.  Mayo  and  others  have  demonstrated  that  there 
is  a  much  greater  relative  frequency  of  duodenal  ulcer  than  was  formerly 
supposed,  but  the  exact  proportion  has  not  yet  been  established.  It  is  likely 
that  many  duodenal  ulcers  have  been  overlooked  in  the  past. 

STOMACH  EXAMINATION 

Examination  of  gastric  function.  Stomach  tube.  AVe  prefer  to  use  a  tube 
of  the  type  devised  by  Smithies.     (See  illustration.) 

It  is  made  of  pure  rubber  that  will  stand  boiling,  is  of  sufficient  calibre 
to  empty  stomachs  containing  residues,  is  marked  off  in  centimeters  from  its 
distal  end  and  thus  acts  as  a  hollow  esophageal  sound  and  has  no  troublesome 
bulb  incorporated  into  it. 

In  the  passage  of  this  tube  the  patient  sits  erect  upon  a  chair,  with  head 
inclined  slightly  forward.  His  hands  are  placed  flat  across  the  abdomen  in 
the  region  of  the  navel.  As  the  tube  glides  through  the  cardiac  orifice,  the 
patient  is  directed  to  lean  forward  from  the  hips  and  exert  sudden  pressure 
with  the  hands  across  the  abdomen.  Usually  there  is  a  prompt  discharge  of 
gastric  contents  from  the  stomach  tube.  If  material  does  not  come  at  once, 
cautious  in-and-out  movements  of  the  tube,  while  the  patient  coughs  deeply, 
generally  start  the  flow.    The  principles  of  siphonage  maintain  it. 

Estimation  of  motility.  At  4  P.  M.  the  patient  is  given  two  ounces  of 
castor  oil  in  one-half  glass  of  beer  or  malt  extract.  At  6  P.  M.  a  generous 
meal  of  mixed  food.  This  meal  may  be  chosen  according  to  the  patient's  de- 
sires, but  should  include  four  ounces  of  meat  and  several  leaves  of  head  let- 
tuce. At  9  P.  M.  the  patient  eats  twenty  raw  raisins,  or  a  handful  of  currants. 
The  patient 's  stomach  is  emptied  at  7  A.  M.  the  following  morning  by  the  aid 
of  a  stomach  tube. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      435 

Interpretation.  If  no  food  remnants  are  present  in  the  stomach,  it  is  safe 
to  assume  that  partial  or  complete  pyloric  obstruction,  or  marked  dilatation 
of  the  stomach,  are  absent.  Twelve-hour  retention  is  exhibited  in  about  75 
per  cent,  of  cancer  cases ;  60  per  cent,  of  surgical  duodenal  ulcers ;  40  per  cent, 
of  surgical  gastric  ulcers  and  in  about  a  like  percentage  of  cases  of  perichole- 
cystitis with  adhesions. 

The  retention  in  the  above  class  of  cases  is  generally  subject  to  demon- 
stration on  several  successive  examinations.  The  degree  of  retention  is  not 
infrequently  modified  by  the  factor  of  pyloric  spasm  being  present  or  absent 
in  such  instances. 

Intermittent  gastric  retention  is  not  infrequently  demonstrated  in  extra- 
gastric  disease  with  pyloric  spasm,  as  where  the  affection  exists  in  the  appen- 


STOiTACH   Tube    (SillTHIES). 

dix  or  gall-bladder.  In  ptosis,  unless  much  atony  co-exists,  the  stomach's 
emptying  power  is  usually  good. 

We  have  found  the  evidences  of  retention  returned  by  gastric  examina- 
tion after  an  eight-to-twelve-hour  interval  to  be  a  much  better  gauge  of  the 
stomach's  ability  to  pass  food  through  than  when  an  examination  for  food 
remnants  is  made  after,  say  a  four-to-six-hour  interval. 

X-ray  method.  From  tAvo  to  four  ounces  of  bismuth  subcarbonate,  or  chem- 
ically pure  barium  sulphate,  are  intimately  mixed  with  eight  ounces  (cooked 
weight)  of  cream  of  wheat  or  oatmeal  porridge.  After  a  six-hour  interval, 
during  which  no  other  food  is  taken,  the  patient  is  examined  by  the  fluoro- 
scopic screen  or  X-ray  plate  for  evidences  of  bismuth  or  barium  in  the  stomach. 
"Where  a  considerable  degree  of  obstruction  to  the  onv/ard  progress  of  food 
exists  (pyloric  stenosis,  hour-glass  contraction,  diverticulum,  etc.),  part  of  the 
shadow-casting  meal  not  infrequently  remains  in  the  stomach  after  six  hours. 
In  gastric  atony  or  marked  pyloric  spasm  similar  retention  is  not  uncommonly 
demonstrated.  Its  demonstration  is  not  constant  on  several  successive  ex- 
aminations in  the  latter  instances. 

Estimation  of  the  secretory  activity  of  the  stomach.  For  this  purpose  a 
test-meal  is  administered.    We  prefer  to  give  one  of  the  following : 

1. — Sixty  grams  of  second-day  bread;  two  glasses  of  water  (one  of  hot  and 
one  of  cold)  ;  or 

2. — Two  toasted  shredded  wheat  biscuits  and  one  glass  of  hot  water  and  one 
of  cold ;  or 

3. — Sixty  grams  of  rusk  or  zweibach  and  250  c.cm.  of  weak  tea  without 
cream  or  lemon  and  preferably  sugar-free.  "^ 

After  the  administration  of  any  of  the  above  meals,  the  patient  should 
walk  about,  read,  or  otherwise  occupy  himself  for  forty-five  minutes.  The 
meal  is  then  removed  by  the  stomach  tube. 


436      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Interpretation  quantity.  Normally  40  to  60  cc.  should  be  obtained  after 
forty-five  minutes.  If  less  is  obtained,  and  one  can  be  sure  that  the  stomach 
is  empty,  hyperperistalsis  can  be  suspected.  If  more  than  the  above  amount 
is  obtained,  hypersecretion,  or  gastric  stagnation,  or  both,  are  not  uncommon. 

Chymification.  Normal  gastric  extracts  have  a  puree-like  appearance.  If 
large,  coarse  or  granular  bits  of  test-meal  food  are  present,  free  hydrochloric 
acidity  is  usually  low.     There  may  be  associated  gastric  atom\ 

Color.  This  varies  with  the  type  of  secretorj"  meal  used.  The  admixture 
of  bile,  traumatic  or  partly-digested  blood  (as  in  cancer  or  ulcer)  causes  varia- 
tions. In  late  stages  of  cancer  "coffee-colored"  contents  are  not  infrequently 
removed,  but  diagnosis  of  cancer  should  never  b€  deferred  until  such  gastric 
contents  are  obtained. 

Odor.  Normal  gastric  extracts  have  a  peculiarly  bland  odor.  High,  free 
hydrochloric  acidity  imparts  a  characteristic  sharp  odor.  In  the  majority  of 
cases  of  benign  retention  (usually  gastric  or  duodenal  ulcer)  the  removed  ex- 
tracts have  a  yeasty  odor.  Where  gastric  stagnation  is  due  to  malignant 
disease  a  peculiar,  rancid  aroma  ("old  cheese"  or  cheap  vinegar  odor)  is 
quite  common.  Sloughing  gastric  growths  or  fistulse  communicating  with  other 
viscera  impart  a  penetrating  "rotten"  odor  to  extracts. 

Chemical  tests.  If  possible,  gastric  extracts  should  be  filtered  after 
thoroughly  mixing  with  a  glass  rod.  If  only  a  few  cubic  centimeters  of  ma- 
terial are  available  tests  for  acidity  may  be  made  upon  unfiltered  extracts. 
The  readings  are  usually  higher  than  where  filtered  extracts  have  been  used. 

Estimation  of  acidity.  1.  QuaUtcdive.— 'Moisten  a  piece  of  pink  Congo- 
paper  with  distilled  water.  Dip  the  wet  end  into  the  gastric  extract  (filtered 
or  unfiltered).  If  free  hydrochloric  acid  is  present,  the  pink  Congo-paper  turns 
blue.  The  rapidity  of  the  change  and  the  intensity  of  the  blue  color  consti- 
tute a  rough  index  of  the  amount  of  free  hydrochloric  acid  present.  In  the 
presence  of  much  organic  acid  (lactic,  acetic,  butyric),  the  pink  Congo-paper 
assumes  a  blue-gray  shade. 

If  the  Congo  test  is  positive  (blue  color)  to  be  sure  that  free  hydrochloric 
acid  is  causing  the  change,  Guenzburg's  test  maybe  made.  Boas'  modification 
is  the  best,  because  the  Boas  solution  is  more  stable  than  the  original  fluid 
proposed  by  Guenzburg.    The  test  solution  has  the  following  formula : 

Resorcin —  5.1         cc. 

Sacchari  albi —  3.  cc. 

Alcohol— dil.  ad.     100  cc. 

Method.  From  two  to  five  drops  of  filtered  gastric  extract  are  intimately 
mixed  with  a  like  quantity  of  the  test  solution  in  a  small  porcelain  dish.  The 
dish  is  then  slowly  heated  over  a  low  Bunsen  flame.  If  gastric  acidity  is  due 
to  free  hydrochloric  acid,  a  lively  cherry-red  or  magenta  color  results. 

Organic  acids.  Volatile,  fatty  acids — as  acetic,  butyric,  etc.,  are  readily 
demonstrated  by  heating  two  or  three  cc.  of  gastric  filtrate  in  a  small  test 
tube  over  a  low  Bunsen  flame.  At  the  mouth  of  the  tube  a  strip  of  moist 
blue  litmus  paper  is  placed.  As  the  fluid  in  the  test  tube  is  brought  to  boiling 
point,  the  fatty  acids  if  present,  volatilize  and  their  fumes  color  the  blue  litmus 
paper  red. 

Qualitative  estimation  of  acidity.  Toepfer's  method  answers  all  practical 
demands. 

•Solutions  needed — (a) — A  1/2  per  cent,  alcoholic  solution  of  dimethylamido- 
azobenzol.    This  is  used  to  determine  free  hydrochloric  acidity. 

b. — A  1  per  cent,  alcoholic  solution  of  phenolpthalein.  This  serves  to  indi- 
cate total  acidity. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  437 

c. — A  deci-normal  solution  of  sodium  hydroxide  (Xa  OHj.  This  should 
be,  preferably,  standardized  by  an  expert  chemist.  Roughly,  the  solution 
is  made  by  dissolving,  with  a  little  heat,  four  ounces  (accurately  weighed;  of 
sodium  hydroxide  in  1000  cc.  of  distilled  water.  The  solution  should  be  kept 
in  a  bottle  tightly  closed  with  a  rubber  stopper.  If  evaporation  is  allowed 
to  take  place  (as  in  a  warm  room;,  the  solution  is  worthless  for  acidity  estima- 
tions. 

Method.  A  burette,  graduated  in  tenths  of  a  cc.  is  partly  filled  with  the 
tenth  normal  sodium  hydroxide  solution.  While  tests  are  being  carried  out, 
it  is  well  to  prevent  alterations  in  the  strength  of  the  soda  solution  by  cover- 
ing the  top  of  the  burette  with  an  inverted  test-tube. 

Ten  cc.  of  the  filtered  gastric  extract  (preferred)  are  accurately  measured 
into  a  porclean  evaporating  dish.  This  may  be  used  to  measure  both  free 
hydrochloric  acidity  and  also  total  acidity.  To  it  are  added  two  drops  of  the 
dimethylamidoazobenzol  solution.  If  free  HCl  is  present  a  lively  cherrj^-red 
color  is  taken  by  the  gastric  filtrate.  If  no  free  HCl  is  present,  the  filtrate 
remains  uncolored  or  assumes  a  pale-yellow  to  orange  tint.  Next,  one  notes 
the  exact  level  of  the  soda  solution  in  the  burette.  It  is  well  for  the  beginner 
to  write  down  this  figure.  The  soda  solution  is  now  allowed  to  fall,  drop  by 
drop,  into  the  porcelain  dish  containing  the  gastric  juice — dimethylamidoazo- 
benzol mixture.  As  the  free  hydrochloric  acid  becomes  neutralized  by  the  soda 
the  cherry-red  color  gradualh'  disappears  and  a  lemon-yellow  tint  is  seen. 
It  is  well  to  keep  the  gastric  extract  stirred  or  shaken  during  this  neutraliza- 
tion, so  that  a  prompt  admixture  of  soda  solution  with  it  takes  place  and  one 
consequently  does  not  over-neutralize  the  acid. 

When  the  color  change  is  complete  (avoid  excess  of  soda  solution),  note 
accurately  the  amount  of  soda  solution  which  has  been  used  in  neutralizing 
the  acid.  This  figure  multiplied  by  ten  (because  we  are  working  with  ten  cc. 
of  juice  on  the  basis  of  one  hundred)  gives  us  the  degree  of  acidity. 

Example — First  burette  reading       11.4 
Second  burette   reading  13.6 


2.2 

2.2x10  equals  22  free  HCl. 

If  five  cc.  of  gastric  juice  only  are  available,  the  cubic  centimeters  of  soda 
solution  used  must  be  multiplied  by  twenty.  To  obtain  the  per  cent,  of  acidity 
multiply  this  by  0.00345. 

Estimation  of  total  acidity.  For  practical  purposes,  total  acidity  may  be 
estimated  from  the  same  specimen  used  in  test  for  free  HCl. 

Mix  into  the  specimen  (which  now  is  of  lemon-yellow  or  orange  color) 
two  or  three  drops  of  solution  of  phenolpthalein.  This  is  the  indicator.  If 
total  acidity  is  not  in  excess  of  the  free  hydrochloric  acid,  the  solution  in  the 
porcelain  evaporating  dish  will  change  from  yellow  to  dark  cherry-red.  If 
total  acidity  is  higher  than  the  free  HCl  then  no  color  change  will  occur  until 
the  existing  acid  has  been  neutralized  by  the  tenth  normal  sodium  hydrate 
solution  from  the  burette.  In  the  latter  event  titration  is  carried  on  as  where 
free  hydrochloric  acid  is  being  estimated.  One  should  note  the  exact  amount  of 
soda  solution  used  to  change  the  yellow  to  cherry-red,  and  be  careful  not  to 
add  soda  solution  after  the  first  uniform  red  color  appears.  If  one  allows  this 
to  happen,  the  readings  will  be  too  high.  This  is  a  common  fault  with  begin- 
ners. The  amount  of  soda  solution  is  multiplied  by  ten,  and  this  added  to  the 
figures  returned  from  the  estimation  of  free  hydrochloric  acid  equals  the  total 
acidity.     Thus : 

Soda  solution  used  in  neutralizing  free  HCl  2.2,  hence  free  HCl  22.0. 


438      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Soda  solution  used  to  neutralize  acidity  with  phenolpthalein  as  per  indica- 
tor 1.6,  or  16. 

Total  acidity  equals  22+16  or  38. 

Estimation  of  combined  acidity  and  acid  salts  is  roughly  determined  by 
subtracting  the  figure  representing  degree  of  free  HCl  from  that  represent- 
ing total  acidity.     Thus : 

Total  acidity     38 
Free  HCl  22 


Combined  acid 
and  acid  salts  16 

Alizarin  is  sometimes  used  as  an  indicator  for  the  more  accurate  estima- 
tion of  "combined,"  or  bound,  hydrochloric  acid.  It  is  titrated  in  gastric 
juice  with  tenth  normal  soda  as  above.  There  is  no  great  practical  advantage 
in  its  use.  Clinically,  a  high  figure  representing  "combined"  acidity  is  found 
in  cases  of  gastric  retention  and  particularly  where  this  retention  is  of  the 
malignant  type. 

Tests  for  lactic  acid.  In  a  test  tube  add  six  drops  of  liquor  ferri  sesqui- 
chlorate  to  three  drops  of  95  per  cent,  carbolic  acid.  Shake  gently.  Add 
distilled  water  until  the  solution  is  amethyst-blue.  Pour  equal  parts  of  this 
mixture  into  two  test  tubes.  One  is  to  be  used  as  control.  Next,  drop  by  drop, 
pour  into  one  of  the  test  tubes  the  filtered  gastric  extract.  If  lactic  acid  is 
present  the  amethyst  color  is  discharged  and  the  contents  of  the  tube  assume  a 
canary-yellow  tint.  This  should  be  compared  with  the  color  in  the  control 
tube.  Doubtful  quantities  of  lactic  acid  have  no  clinical  significance.  Easily 
recognizable  quantities  of  lactic  acid  are  noted  in  late  cancer  quite  uni- 
formly. In  rare  instances  of  benign  pyloric  obstruction  or  gastric  atony  (par- 
ticularly if  the  patient  has  been  on  milk  or  sour  milk  diet),  lactic  acid  may  be 
demonstrated. 

Strauss  has  improved  the  above  technique  for  testing  for  lactic  acid  by 
using  the  ether  extract  of  the  gastric  filtrate. 

Chemical  test  for  altered  blood  ("occult  blood")  in  gastric  extracts  or 
feces.  Benzidin  test — Solutions  needed:  (a)  1  per  cent,  alcoholic  solution 
of  chemically  pure  benzidin  (pink  powder)  in  95  per  cent,  alcohol  or  strong 
acetic  acid,  (b)  Pure  ether,  (c)  Glacial  acetic  acid,  (d)  Strong  solution  of 
hydrogen  peroxide. 

Method.  Three  to  five  cc.  of  gastric  extract  (non-filtered)  are  placed  in  a 
test  tube.  To  this  are  added  five  to  ten  drops  of  glacial  acetic  acid  (to  separate 
the  hematin,  forming  an  acid  hematin).  Mix  thoroughly.  Next  add  two  to 
three  cc.  of  ether  and  mix  the  contents  of  the  tube  by  pouring  from  one  test 
tube  to  another  several  times.  Allow  to  stand  now  for  several  minutes  until 
the  clear  ethereal  extract  floats  above  the  semi-solid  gastric  contents.  This 
ether  extract  contains  the  acid  hematin,  if  any  is  present.  Pour  it  off  into  a 
clean  test  tube.  To  this  now  add  fifteen  drops  of  the  standard  benzidin 
solution ;  mix.  Next  add  one  to  three  cc.  of  the  peroxide  of  hydrogen  solution. 
If  blood  is  present  the  contents  of  the  tube  promptly  take  on  a  brilliant 
emerald-green  hue.  If  much  blood  is  present  this  rapidly  changes  over  to  a 
deep  ultramarine.  If  the  color  change  does  not  appear  within  one  minute  we 
consider  that  the  amount  of  altered  blood  present  has  no  clinical  significance. 

Feces  are  examined  similarly  to  the  gastric  extract.  The  properly  pre- 
pared stool  only  should  be  used.  This  is  obtained  by^  placing  the  patient  on  a 
meat-  and  meat-product-free  diet  for  three  days.  On  the  day  that  the  stool  is 
to  be  obtained  the  patient  takes  no  food  other  than  milk  and  bread.    The  sec- 


SURGERY  OF  THE  ESOPHAGUS  AND  STOIVIACH  439 


X-T?AY  PlCTTTRE    OF   StomACH. 

Eadiograni  of  stomach,  showing  eareinoma  involving  pylorus,  antrum  and  crreater 
eurva  ure  (A).  Note  obliteration  of  pylorus  and  antruS,  irregular  oXne  of  oz eater 
curvature  and  absence  of  visualization  of  the  duodenum.  „i  eater 


440 


SUKGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


X-Eay  of  the  Pylorus. 

Radiogram  showing  calloused  ulcer  at  the  pylorus  snd  lesser  curvature.  Note 
irregular  outline  of  lesser  curvature  (antral  portion),  and  pylorus,  with  incomplete 
vifcualization  of  the  bulbus  duodeni. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


441 


X-Eay  op  the  Pylorus. 

Eadiogram  showing  perforating  ulcer  at  pylorus.     Note  irregular  pyloric  end, 
with  small,  tent-like  loculus  on  the  pyloric  portion  of  the  lesser  curvature. 


442  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


X-Eay  of  Gastric  TTlceb. 
Eadiogram  showing  chronic  perforating  ulcer  of  the  lesser  curvature,  near  the  pylorus. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      443 

ond  stool  passed  should  be  tested.  A  mild  saline  (as  citrate  of  magnesia)  may 
be  used  to  secure  free  opening  of  the  bowels. 

One  now  proceeds  exactly  as  in  the  method  outlined  above  for  testing 
gastric  extracts.  If  the  stool  is  hard  and  formed,  it  may  be  rendered  semi- 
fluid by  mixing  with  distilled  water.  The  color  changes  after  the  addition  of 
the  peroxide  of  hydrogen  correspond  with  those  resulting  when  blood  is  pres- 
ent in  gastric  extracts. 

Interpretations  of  the  test  for  altered  blood  are  entirely  individual.  One 
should  be  sure  that  the  subject  is  not  bleeding  from  mouth  lesions  (after  tubing 
to  obtain  gastric  extracts),  hemorrhoids,  fissures,  etc.  If  these  have  been  elim- 
inated as  sources  of  bleeding,  then  the  chemical  demonstration  of  blood  means 
that  there  is  a  bleeding  focus  somewhere.  It  is  the  business  of  the  physician 
to  locate  this.  Bleeding  of  this  type  occurs  intermittently  in  acute  or  chronic 
peptic  ulcer,  and  usually  continuously  in  fresh  erosions,  ulcera  carcinomatosa 
and  gastric  cancer,  cancer  of  the  esophagus,  or  the  large  bowel. 

Test  for  ferments — Pepsin — Mett's  method.  Thin- walled  glass  tubing  hav- 
ing a  calibre  of  1.5  mm.  is  cleaned  thoroughly  and  dried.  It  is  then  cut  into 
convenient  lengths,  say  ten  cm.  These  are  filled  by  suction  with  fresh  white- 
of-egg  which  has  been  filtered  through  several  layers  of  fine  gauze.  If  the 
more  solid  parts  of  the  albumin  are  taken  up  one  can  avoid  air  bubbles.  As 
each  tube  is  filled  the  ends  are  passed  through  a  Bunsen  flame  and  sealed. 
When  the  required  number  of  tubes  has  been  filled  they  are  placed  in  a  pan 
containing  distilled  water.  They  may  be  kept  from  the  bottom  of  the  pan  by 
allowing  them  to  rest  on  glass  rods.  The  temperature  of  the  water  is  slowly 
brought  up  to  ninety-five  degrees  C.  and  this  temperature  is  maintained  until 
the  albumin  in  the  tubes  is  coagulated.  This  takes  about  five  minutes.  The 
tubes  may  be  preserved  in  sixty-six  per  cent,  watery  solution  of  glycerin  until 
needed.  To  make  the  test,  take  out  one  tube,  cut  about  two  cm.  from  it  and 
wash  in  distilled  water.  Place  this  in  a  small  bottle  or  test  tube  containing 
three  to  five  cc.  of  filtered  gastric  extract ;  cork  and  place  in  an  incubator  for 
from  ten  to  twenty-four  hours.  If  pepsin  is  present  in  the  presence  of  free 
HCl  one  notes  disappearance  or  partial  disappearance  of  the  egg  clot  in  the 
glass  tube.  This  can  be  estimated  as  mm.  of  digestion.  It  is  stated  that  nor- 
mal peptic  digestion  is  from  3.5  to  4.5  mm.  in  twenty-four  hours.  In  subacidity 
and  anacidity  lower  values  are  obtained,  while  in  hyperacidity  the  peptic 
digestion  is  commonly  increased. 

A  simpler,  but  less  exact  test,  may  be  made  by  dropping  a  small  disc  (made 
with  a  cork-borer  from  a  hard  boiled  egg)  of  egg-white  into  a  test  tube  con- 
taining from  three  to  five  ce.  of  gastric  filtrate.  Place  in  an  incubator  at  37°  C. 
for  twenty-four  hours.  In  the  presence  of  free  HCl,  if  pepsin  is  present,  the 
egg-white  disc  becomes  translucent  at  its  edge.  Roughly,  the  amount  of  pepsin 
can  be  gauged  by  noting  the  depth  of  this  translucent  area. 

Test  for  rennin  and  its  zymogen.  One  cubic  centimeter  of  gastric  filtrate 
is  added  to  fifteen  cc.  of  fresh,  alkalinized  milk  in  a  test  tube.  '  This  is  placed 
in  an  incubator  at  37  degrees  C.  If  normal  quantity  of  the  ferment  is  present, 
coagulation  will  occur  within  fifteen  to  thirty  minutes.  If  no  hydrochloric  acid 
is  present  in  the  gastric  filtrate,  add  to  the  gastric  juice-milk  mixture  five  drops 
of  a  solution  of  calcium  chloride.  If  rennin  zymogen  is  present,  the  calcium 
salt  converts  it  into  rennin,  which  will  then  clot  the  milk. 

Test  for  peptid  splitting  enzymes  in  gastric  extracts.  (Carcinoma  test  of 
Neubauer  and  Fischer).  Smithies  advises  the  following  modification:  The' 
test  is  set  up  as  follows:  1.  Test-tubes  of  ten  cc.  capacity  are  employed.. 
These  should  be  carefully  cleaned  with  boiling  water  and  dried  inside.  They 
are  numerically  marked  for  identification  with  a  wax  pencil.  Into  each  test- 
tube  is  carefully  measured,  by  means  of  a  sterile  graduated  pipette,  0.5  cc.  of 


I 


444  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

the  glycyltryptophan  solution.  (Closing  the  proximal  end  of  the  pipette  with 
a  finger  allows  the  pointed  distal  end  to  pass  through  the  toluol  layer  overlying 
the  glycyltryptophan  solution,  and  the  dipeptid  to  be  withdrawn  with  the  min- 
imum of  contamination.)  Five  ee.  of  the  recently  secured,  filtered  gastric 
extract  are  then  measured  by  a  clean,  graduated  pipette  and  poured  into  the 
corresponding!}^  numbered  test  tubes  to  which  glycyltryptophan  solution  has 
been  already  added.  Two  control  tubes  are  used.  In  one  is  placed  0.5  cc.  of 
glycyltrjqjtophan  solution  and  5  cc.  of  normal  salt  solution  and  into  the  other 
is  placed  5  cc.  of  normal  salt  solution,  with  added  glycyltryptophan  solution. 
In  the  entire  series,  each  tube  next  receives  0.5  cc.  of  toluol  (Toluene,  JNIerck). 
The  contents  of  the  tubes  are  then  mixed  by  inverting  several  times.  The 
tubes  are  next  placed  in  a  water-bath  (an  incubator  may  be  used)  at  37°  C.  for 
twenty-four  hours. 

2.  At  the  expiration  of  the  incubation  period,  the  test  tubes  are  removed 
from  the  water-bath.  Clean  test  tubes  of  10  cc.  capacity  and  numbered  to  cor- 
respond with  the  gastric  extracts  tested,  as  well  as  the  controls,  are  set  in 
racks.  Into  each  of  these  tubes  is  measured,  by  means  of  a  graduated  pipette, 
5  cc.  of  the  glycyltryptophan-gastric-extract  mixture  lying  below  the  toluol  in 
the  recently  incubated  tubes.  To  each  tube  are  then  added  three  drops  of  a 
three  per  cent,  glacial  acetic  acid  in  distilled  water  solution.  The  tubes  are 
well  shaken.  Bromin  vapor  is  allowed  to  flow  into  each  tube,  until  it  appears  J 
amber-3^ellow  above  the  contained  fluid.  The  tubes  are  again  shaken.  Exam-H 
ination  by  daylight  (preferred)  or  by  white,  artificial  light  is  now  made  for' 
evidences  of  the  characteristic  rose-pink  reaction  between  the  aminO-acid 
(tryptophan)  and  the  bromin. 

Tr3rptophan  test.  As  suggested  by  Weinstein,  this  is  made,  as  routine,  on 
the  fresh  gastric  extracts.  Inasmuch  as,  occasionally,  swallowed  saliva,  amino- 
acids,  regurgitated  duodenal  contents  and  the  like  may  give  the  bromin  vapor 
reaction,  before  incubation  or  without  the  addition  of  a  dipeptid  such  as 
glycyltryptophan.  Five  cc.  of  each  fresh,  filtered  gastric  extract  is  poured  into 
test-tubes  of  ten  cc.  capacity,  acidulated  with  the  three  per  cent,  acetic  acid 
solution  and  treated  with  bromin  vapor  as  above.  If  no  characteristic  rose- 
pink  color  results  the  tubes  are  incubated  with  the  corresponding  specimens 
that  have  been  mixed  with  glycyltryptophan  solution.  For  accurate  work,  it 
has  seemed  best  to  us  to  cover  these  "tryptophan  test"  contents  with  a  layer 
of  toluol.  At  the  end  of  twelve,  twenty-four  and  forty-eight  hours,  note  is 
made  of  changes  in  color,  and  these  results  are  compared  with  those  obtained 
with  the  preparations  in  the  first  series. 

Wolff -Junghan's  test  for  soluble  albumin  (used  to  differentiate  malignant 
from  benign  achylias).  Smithies  advises  the  following  manner  of  performing 
this  test :  The  day  previous  to  the  examination  of  his  gastric  extract  the 
patient  is  given  one  ounce  of  castor  oil  at  4  P.  M.  This  is  followed  at  6  P.  M. 
by  a  motor  test-meal  consisting  of  mixed  food.  At  7  P.  M.  twenty  raw,  seedless 
raisins  are  given.  Twelve  hours  later  (7  A.  M.  the  following  morning)  the 
patient  is  fed  sixty  grams  of  second-day  bread  and  two  hundred  cc.  of  water. 
This  secretory  test-meal  is  removed  from  fifty  to  sixty  minutes  after  admin- 
istering. The  specimen  secured  is  thoroughly  mixed,  filtered  through  double 
hydrochloric-acid-washed  papers,  and  tested  for  dissolved  albumin  within  an 
hour  of  its  being  obtained  from  the  stomach.  On  account  of  the  fact  that,  as 
has  been  shown,  but  52.2  per  cent,  of  cases  of  gastric  cancer  yield  gastric 
extracts  revealing  absence  of  free  hydrochloric  acid,  and  that  in  15.7  per  cent, 
of  cases,  free  hydrochloric  acid  ranges  between  twenty  and  fifty  per  cent,  we 
have  deemed  it  advisable  to  apply  the  test  for  soluble  albumin  not  only  to 
achylias,  but  also  to  gastric  extracts  where  the  free  hydrochloric  acid  was 
below  twenty  per  cent.    In  a  few  instances  of  suspected  malignant  ulcer  we 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  445 

have  performed  the  test  upon  gastric  extracts  with  higher  free  hydrochloric 
acid  content.  In  such  we  have  been  fnlly  alive  to  the  possibilities  of  error,  but 
for  the  purpose  of  gaining  information  and  for  comparison  we  have  deemed  it 
wise  to  make  the  test. 

Procedure.  Six  absolutely  clean  test-tubes  are  required  for  each  test. 
Those  of  the  narrow  type  and  of  twenty  cc.  capacity  answer  very  well.  The 
tubes  are  numbered  serially  from  one  to  six.  They  receive  respectively  one  cc, 
0.5  cc,  0.06  cc.  and  0.025  cc  of  the  filtered  gastric  extract.  These  amounts  are 
readily  measured  by  means  of  a  one  ec  pipette,  graduated  in  1  1/100  cc.  By 
means  of  a  10  cc  pipette,  graduated  into  1  1/100  cc,  the  volume  in  each  test- 
tube  is  next  consecutively^  brought  up  to  ten  cc  volume  with  distilled  water. 
This  gives  from  the  tubes  one  to  six  dilutions  of  gastric  juice  varving,  respec- 
tively, from  1  to  10  to  1  to  400  (viz.,  1  to  10,  1  to  20,  1  to  40,  1  to  ioO,  1  to  200, 
and  1  to  400).  These  figures  we  have  termed  "units"  of  precipitable  albumin. 
The  tubes  are  then  inverted  several  times  to  insure  complete  mixture  of  their 
contents.  One  cc.  of  the  reagent  to  precipitate  the  albumin  in  solution  is  then 
carefully  layered  upon  the  contents  of  each  tube.  The  precipitating  reagent 
suggested  by  Wolff  has  proved  satisfactory^  with  us.  It  has  the  following 
formula : 

Phosphotungstic  acid   (puriss) 3  cc 

Hydrochloric  acid   (concentrated) 10  cc 

Alcohol  (96  per  cent.) 200  cc. 

Aq.  dest.  q.s.a.d 2000  cc. 

Mix  and  keep  in  a  glass  or  rubber-stopped  flask  in  a  cool  place. 

Manifestation  and  interpretation  of  the  test.  If  there  has  been  dissolved 
albumen  in  any  of  the  tubes,  the  juncture  of  the  "Woltf  reagent  with  the  diluted 
gastric  extracts  is  marked  by  a  pearh^-white  zone  or  "ring."  This  is  better 
brought  out  if  the  tubes  are  inspected  against  a  black  background.  (We  have 
used  a  piece  of  black  cloth  such  as  photographers  employ  when  focussing 
cameras.)  The  tubes  should  be  inspected  at  once  after  adding  the  "Woltf  solu- 
tion. Prolonged  standing  allows  cloudy  zones  to  form  which  render  compara- 
tive interpretation  dubious. 

AVe  have  interpreted  our  results  after  "VToltf  and  Junghans'  suggestion 
thus:  If  the  white  ring  of  precipitated  albumin  appears  in  tubes  ],  2  and  3 
(namelj",  units  of  albumin  from  10  up  to  50)  and  no  further  manifestations  are 
present  in  the  remaining  three  tubes,  we  have  called  the  test  negative.  If 
tubes  1,  2,  3,  and  4  exhibit  rings  (units  of  albumin  from  10  to  100)  we  have 
considered  the  reaction  doubtful.  The  presence  of  white  rings  in  tubes  1,  2, 
3,  4,  5  and  above  (units  of  albumin  ranging  from  10  to  200  to  400)  we  have 
taken  to  denote  a  positive  test. 

Clinical  value.  1.  AYhen  carefully  performed  and  interpreted  the  "Wolff- 
Junghans  test  for  demonstration  of  dissolved  albumin  in  gastric  extracts  was 
positive  or  suspicious  in  eighty  per  cent,  of  our  series  of  gastric  cancer.  In 
this  series  it  was  a  more  constant  finding  in  gastric  extracts  than  were  absent 
free  hydrochloric  acid,  the  presence  of  lactic  acid,  and  the  glycyltryptophan 
test.  It  was  rather  more  constant  than  tests  for  occult  blood  and  the  demon- 
stration of  gastric  motor  inefficiency.  It  was  not  so  consistent  in  its  manifesta- 
tion as  the  demonstration  of  organisms  of  the  Boas-Oppler  group  or  the 
increase  in  the  formol  index. 

2.  In  extragastric  malignancy,  gastric  syphilis,  and  nephritis  the  "WolfF- 
Junghans   test   is  inconstant. 

3.  In  the  differentiation  between  malignant  and  non-malignant  achylias 
the  "Wolff-Junghans  test,  when  interpreted  in  connection  with  other  clinical 
and  laboratory  data,  is  of  considerable  value.     Positive  reactions  are  rarely 


446      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

obtained  in  the  aehylias  of  primary  anemia,  simple  achylia  gastrica,  and  simple 
aehlorhydrias  when  such  are  unassociated  with  gastric  motor  inefficiency. 

4.  Simple  gastric  and  duodenal  ulcers,  especially  when  accompanied  by 
pyloric  stenosis  or  gastric  atony,  may  give  confusing  responses  to  the  "Wolff- 
Junghans  test. 

5.  The  presence  of  blood  in  gastric  extracts  may  be  a  factor  in  the  produc- 
tion of  certain  atypical  positive  tests. 

Test  for  bile.  Fuming  nitric  acid  is  prepared  by  gently  beating  a  few  bits 
of  match-wood  in  concentrated  nitric  acid.  A  large  drop  of  gastric  juice  is 
placed  on  a  sheet  of  filter  paper.  A  similar  drop  of  the  fuming  nitric  acid  is 
placed  on  the  same  filter  paper  in  such  manner  that  its  "spread"  meets  that  of 
the  gastric  juice.  If  bile  be  present  a  rainbow-like  play  of  colors  appears  at 
the  junction  zone  of  the  two  drops. 

Floating  nitric  acid  upon  two  or  three  ec.  of  gastric  juice  in  a  small  porce- 
lain evaporating  disk  likewise  serves  to  demonstrate  the  play  of  colors  if  bile 
be  present. 

Microscopic  examination  of  gastric  extracts.  The  unfiltered  extracts  are 
used.  A  rapid  method  is  to  place  three  small  drops  of  the  removed  contents 
about  one  cm.  apart  upon  a  glass  slide  thus : 

To  drop  2  is  added  one  small  drop  of  normal  iodine  solution  (starch 
stain)  or  of  Lugol's  fluid;  to  drop  3  one  small  drop  of  osmic  acid  (fat  stain)  ; 


drop  1  is  left  unstained.  Cover  slips  are  now  pressed  down  firmly  upon  the 
drops.  The  specimens  should  be  examined  with  the  oil  immersion  (preferred) 
on  the  1/6  objectives. 

Better  preparations  are  made  by  making  thin  smears  of  unfiltered  gastric 
extracts  upon  cover  slips,  after  the  manner  of  making  blood-smears.  These 
are  dried  by  rapidly  passing  through  a  Bunsen  flame.  They  may  then  be 
stained  with  Unna's  polychrome  methjdene-blue,  or,  if  many  specimens  are  to 
be  quickly  examined,  by  color-agar  method  devised  by  Smithies. 

Interpretation.  Smithies  states  that  after  the  examination  of  7,041  cases, 
starch  digestion  is  not  a  constant  index  of  the  acidity  of  the  stomach  juice. 
Diastatic  action  of  saliva  depends  more  on  motor  conditions  than  upon  secre- 
tory. The  character  of  the  ingested  food  is  a  modifying  factor.  In  some 
instances  of  low  gastric  acidity,  with  normal  motility,  it  would  seem  that  an 
anti-diastase  were  present  in  gastric  extracts. 

Microscopic  remnants  of  the  motor  meal  have  no  diagnostic  significance 
other  than  that  indicated  when  found  in  association  with  food  microscopically. 

The  diagnostic  significance  of  the  micro-organisms  in  gastric  extracts. 
From  our  studies  we  have  developed  four  microscopic  pictures  which  seem 
almost  pathognomonic  for  certain  types  of  disease.  Apart  from  these  we  can 
see  nothing  very  significant.  Certainly  high  gastric  acidity  by  no  means 
insures  bacteriologic  cleanliness. 

Complex  1;  that  of  benign  gastric  retention  (usually  ulcer).  In  89  per  cent, 
of  our  cases  of  this  type,  the  presence  of  large  numbers  of  actively  budding 
yeast,  associated  with  large  and  small  sarcinse  and  bacilli,  apparently  of  the 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


447 


X-Eay  of  Dilated  Stomach. 

Radiogram   showing  greatly   dilated  stomach,  gastric,   atony,  chronic  ulcer   on  the  lesser 
curvature  near  the  pylorus  and  dilated  duodenum. 


448 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


4 


i 


X-RAY    of    L»ILATED    tSTOMACH. 

Eadiogram  showing  dilatation  of  the  stomach,  active  i)yloric  peristalsis,  ulcer  of 
the  duodenum  adherent  to  the  lesser  curvature  near  the  pylorus. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


449 


X-Eay  of  ''Steer-horn"  Stomach. 

Eadiogram  showing  large  steer-horn  stomach  pulled  over  to  the  right  and  held  there  by 
adhesions  from  the  gall  bladder  to  the  duodenum  and  pylorus.     Moderate  pyloric  obstruction. 


?f! 


450 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


X-KaY    of     '  '  iiOUK-GLASS  '  ''     CONTRACTION     OF    STOMACH. 

Hadiogram  of  stomach  showing  hour-glass  contraction  due  to  saddle,  calloused  ulcer 
(pars  media). 


SUHGERY  OF  THE  ESOPHAGUS  AXD  STOI^IACH  451 

colon  group,  and  food  bits  were  demonstrated.  The  gastric  acidity  was  gen- 
erally above  50. 

Complex  2;  thai  of  gastric  cancer.  In  93.8  per  cent,  of  all  our  proved  late 
malignant  cases,  organisms  of  the  Boas-Oppler  group,  associated  with  food 
retention,  and  acid  averaging  below  10,  was  a  characteristic  picture.  In  but 
30  per  cent,  of  instances  were  budding  yeasts  concomitant.  In  but  10  per 
cent,  were  sarcinae  associated.  Threads  of  streptococci  were  found  in  6.2  per 
cent,  and  these  usually  in  the  non-retention  group.  There  is  no  characteristic 
microscopic  picture  of  early  gastric  cancer,  other  than  that  associated  with 
gastric  ulcer  of  the  retention  type.  In  less  than  1  per  cent,  of  our  cases  of 
gastric  cancer  were  we  able  to  demonstrate  so-called  '■cancer  cells"  with  active 
mitoses.  These  were  all  late  cases  or  cases  where  the  cardiac  orifice  was  in- 
volved with  a  sloughing  growth.  In  this  class  of  cases  a  diagnosis  can,  of 
course,  be  made  from  the  history  and  physical  examination. 

Complex  3;  ackylia  gastrica — primary  or  secondary.  In  gastric  extracts 
of  low  or  absent  hydrochloric  acid,  where  there  is  atrophy  of  the  mucosa  and 
where  motility  is  not  interfered  with,  there  are  found  long  chains  of  strepto- 
cocci (resembling  beads  of  a  rosaryj  ;  groups  of  large,  deep-staining  cocci, 
and  a  peculiar,  short,  fa*,  acid-fast  rod  or  cocco-bacillus  that  grows  in  short 
chains,  pairs  or  alone. 

Complex  4;  where  perforation  into  an  adjacent  viscus  has  taken  place  in 
malignant  ulcer  or  primary  cancer,  or  where  obstruction  has  occurred  below 
the  duodenum,  the  picture  of  immense  numbers  of  thick  cocco-bacilli,  with  or 
without  spirillse  or  streptococci,  in  association  with  low  acidity,  retarded  food 
progress  and  putrefaction  as  evidenced  by  the  odor,  is  shown  in  more  than  91 
per  cent,  of  instances. 

Examination  of  feces.  Much  can  be  learned  by  examination  of  the  stool, 
passed  without  catharsis.  One  should,  however,  know  approximately  upon 
what  diet  the  patient  is  subsisting.  The  stool  is  generally  greater  in  amount 
upon  a  carbohydrate  than  upon  a  proteid  diet.  I\Iore  than  250  grains  is  con- 
sidered an  abnormal  amount  for  a  healthy  individual  to  pass  at  one  time. 

Normal  stools  are  usually  cylindrical  and  firm,  but  for  a  given  individual  a 
mushy  stool  may  not  be  abnormal ;  small,  hard,  round  scybalous  masses  gen- 
erally indicate  that  the  stool  has  been  delayed  in  the  large  bowel.  Quantity 
of  stool  is  often  greatly  increased  in  pancreatic  insufficiency.  Diarrheic  stools 
are  not  uncommon  in  achylia  gastrica,  pernicious  anemia,  gastric  cancer,  pan- 
creatic disease,  protozoic  colitis,  acute  inflammation  of  the  gastro-intestinal 
tract,  at  the  onset  of  acute  infectious  diseases  Qa  grippe) — ^metallic  poisoning, 
dietetic  errors,  etc.  Nervous  individuals  may  have  periodic  diarrhea  at  times 
of  menstruation  or  during  psychic  strain. 

Color.  This  varies  much  according  to  diet,  "^hen  the  patient  is  upon 
normal  diet,  light-yellow  stools  are  associated  with  deficient  production  of  bile 
or  interference  with  its  free  passage  into  the  bowel :  large,  bright  colored, 
greasy  stools,  intermixed  with  chunks  of  undigested  food  or  gobs  of  unbroken- 
up  fat  (resembling  butter  or  egg  yolk)  are  common  in  chronic  pancreatic 
disease ;  tar-colored  or  brownish-black  stools  (provided  no  medicine  such  as 
bismuth,  iron,  etc.,  is  being  taken)  generally  mean  partly  digested  blood ; 
frank  hemorrhage  colors  stools  red ;  green  stools  may  occur  from  excessive  use 
of  calomel,  over-production  of  bile,  diet  (spinach,  green  beans,  etc.),  or  growth 
of  a  chlorophyllaceous  mould ;  stools  of  varius  color  may  result  from  internal 
administration  of  carmine,  santonin,  rhubarb,  charcoal,  senna,  hematoxylin, 
etc. 

Eice-water  stools  (cholera)  '^pea-soup"  stools  (typhoid)  or  mucilaginous 
stools  (catarrhal  states  of  the  large  bowel),  are  fairly  pathognomonic  of  the 
diseases  with  which,  they  are  associated. 


452      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Odor.  Skatol  and  indol  impart  disagreeable  odors  to  normal  stools.  Spe- 
cial foods,  fermentation,  sloughing  tissue  or  administered  medicines  may  char- 
acteristically change  this  odor. 

Gall-stones  are  rarely  found  in  stools.  In  suspected  cases  washing  the  stool 
with  water  as  it  lies  on  a  thin-meshed  sieve  may  enable  one  to  recover  stones. 
Lumps  of  oil,  soap  and  the  like,  are  frequently  mistaken  for  gall-stones. 

Pus  generally  comes  from  abscess  cavities  discharging  into  the  bowel. 
Dysentery  or  tuberculosis  should  be  suspected. 

Chemical  test  of  feces.  Blood.  This  has  alreadj^  been  described  under 
gastric  examination. 

Acidity.  Kaplan  suggests  rubbing  up  five  grams  of  feces  in  thirty  cc.  of 
distilled  water.  Into  a  small  porcelain  evaporating  dish  pour  two  cc.  of  the  re- 
sultant emulsion.  Add  three  drops  of  1  per  cent,  alcoholic  solution  of  phenol- 
phthalein  as  an  indicator.  Now  titrate  to  a  pink  color  with  tenth  normal 
sodium  hydroxide  solution  and  estimate  acidity  as  in  the  case  of  gastric  juice. 
A  normal  stool  after  a  Schmidt  test  diet  requires  about  one  and  five  tenths  cc. 
of  tenth  normal  sodium  hydrate  solution  to  neutralize  two  cc.  of  stool  emulsion. 
In  fermentation,  this  acidity  may  be  increased  or  diminished. 

Schmidt  test  diet.  Morning,  8  A.  M.  i^  litre  (500  cc.)  raw  milk  (or  if 
milk  disagrees,  Yo  litre  cocoa  made  from  400  cc.  water,  100  cc.  milk,  20  grams 
cocoa  powder  and  10  grams  sugar). 

Forenoon,  10  A.  M.  14  litre  oatmeal  gruel  (40  grams  oatmeal,  10  grams 
butter,  200  cc.  milk,  300  cc.  water  and  1  egg  strained). 

Noon,  12:00.  125  grams  chopped  beef  (raw  weight),  broiled  rare  with  20 
grams  butter,  250  grams  potato  broth  (made  of  190  grams  mashed  potato, 
100  cc.  milk  and  10  grams  butter). 

Mid-afternoon,  3  P.  M.     Same  as  morning. 

Evening,  6  P.  M.    Same  as  forenoon. 

This  should  be  used  in  all  cases  where  accurate  observation  of  the  digestive 
ability  of  the  pancreas  is  desired. 

Test  for  bile  pigments.  (Schmidt.) — Light-colored  stools  do  not  necessarily 
mean  that  bile  ducts  are  obstructed  or  that  liver  function  is  absent.  Diet  or 
failure  of  fat  digestion  may  closely  simulate  alcoholic  stools.  To  determine 
the  presence  or  absence  of  bile  pigment,  grind  up  five  grams  (five  cc.  in  case 
of  a  fluid  stool)  with  twenty  cc.  of  saturated  solution  of  bichloride  of  mercury 
in  distilled  water.  Allow  to  stand  a  few  minutes.  Pour  ofT  the  supernatant 
fluid  into  a  Petrie  dish  and  cover.  Place  the  dish  upon  a  sheet  of  white  filter 
paper.  If  bile-pigments  are  present,  within  twelve  hours  the  fluid  in  the  Petrie 
dish  will  assume  a  greenish  (biliverdin)  or  pink  (bilirubin)  hue.  This  is  a 
very  reliable  and  rapid  routine  test. 

Tests  for  pancreatic  function.  (Gross — Fuld — ^Wohlgemuth.) — This  test 
has  for  its  object  the  demonstration,  quantitatively,  of  the  presence  or  absence 
of  the  pancreatic  ferments,  trypsin  (proteid-cleaving)  and  amylopsin  (carbo- 
hydrate-cleaving). It  has  certain  limitations,  but  is  the  most  dependable  clin- 
ical test  that  we  at  present  have  for  obtaining  information  respecting  the 
enzyme  power  of  the  pancreas. 

Test  for  pancreatic  ferments.  First  the  patient  should  be  put  upon 
Schmidt  test-diet  for  twenty-four  hours.  To  obtain  a  stool  for  ferment  exam- 
ination, calomel  two  to  three  grains,  or  phenolphthalein  five  grains,  is  to  be 
preferred  to  salts.  At  bed-time  collect  the  second  stool  passed.  The  Fuld- 
Gross-AVohlgemuth  test  uses  for  trypsin  testing  a  solution  of  casein,  ten  grams ; 
sodium  carbonate,  ten  grams ;  chloroform,  ten  cc.  to  one  litre  of  water.  If  the 
stool  is  not  very  liquid  five  grams  of  feces  are  rubbed  up  with  twenty  cc.  salt 
solution  and  filtered.  Dilutions  of  1  to  10,  1  to  100  and  1  to  1000  are  made 
and  five-tenths  and  one  cc,  and  two  cc.  of  these  dilutions  added  to  nine  test 


SURGEEY  OF  THE  ESOPHAGUS  AND  STOMACH  453 

tubes  each  containing  five  cc.  of  the  casein  solution.  The  tubes  are  incubated 
for  twenty-four  hours  at  thirty-eight  degrees  C.  and  completion  of  the  diges- 
tion tested  by  adding  five  per  cent,  acetic  acid,  which  should  not  cause  a 
precipitate  in  tubes  in  which  digestion  is  complete. 

The  estimation  is  made  by  units,  one  unit  being  the  digestive  power  of  one 
cc.  of  feces  filtrate  to  digest  one  cc.  of  casein  solution.  If  1  cc.  of  the  1  to  1000 
feces  dilution  digested  5  cc.  of  casein  solution  it  would  represent  5000  units. 
If  1  cc.  of  1  to  10  dilution  it  would  be  50.  As  there  are  5  cc.  of  the  casein 
solution  we  multiply  the  dilution  of  feces  by  5  for  1  cc.  or  by  10  if  we  had 
only  0.5  cc.  of  feces  dilution  in  the  tube  tested. 

For  amylopsin  a  similar  technic  is  followed,  using  a  1  per  cent,  solution 
of  soluble  starch  instead  of  the  1  per  cent,  casein  or  Lugol's  solution.  The 
end  reaction  is  tested  by  adding  1  drop  of  1/10  iodine  solution  to  each  of  the 
starch  tubes  and  feces  dilution  after  twenty-four  hours  of  incubation.  The 
absence  of  a  blue  color  shows  completion  of  starch  digestion. 

The  normal  ferment  content  of  the  feces  rarely  falls  below  200  units  and 
may  be  as  high  as  10,000.  Cases  shovvdng  a  ferment  value  of  only  25  to  50 
units  are  very  suspicion^  as  regards  pancreatic  disease. 

Gastric  ulcer — Diagnosis.    I. — Facts  determined,  from  history. 
{&) — Frequently,  dietetic  or  hygienic  irregularities.    Males  are  more  fre- 
quently affected  than  are  females, 
(b) — History  of  recurring  acute  infections.     (La  grippe — tonsilitis,  exan- 
themata, etc.j.     Seasonal  relation  of  distress  not  uncommon,  ex- 
acerbations occurring  in  fall  or  sprin,g. 
(c) — Association  with  disease  of  appendix  or  gall-bladder   (with  which 
ulcer,  especially  in  subjects  below  age  of  thirty,  is  often  confused), 
(dj — Periodicity  of  complaint   occurs  in  from  75  to  85  per  cent,  until 
complications  set  in.    Between  "spells"  or  attacks  of  indigestion, 
so-called,  there  is  generally  good  gastric  health.     Weight  is  not 
infrequently  lost  during  attacks  and  rapidly  gained  when  such 
cease. 
_(e) — Epigastric  distress  present  in  more  than  95  per  cent.    Varies  in  sever- 
ity from  discomfort  to  severe,  gnawing  or  cramp-like  pains.     Dis- 
comfort has  point  of  maximum  location,  subjectively,  in  practically 
three  out  of  four  cases.    Pain  has  usually  reached  its  height  within 
four  hours  following  meals.     Pain  comes  on  sooner  post  cibo  in 
ulcers  located  near  the  cardia  than  where  such  are  well  towards 
the  pylorus. 
(f) — Food  relief  of  distress  occurs  in  four  out  of  five  instances  of  peptic 
ulcer  of  the  uncomplicated  type.    Kelief  of  pain  frequently  bears 
relation  to  amount  of  food  taken,  i.  e..  a  large  meal  gives'  longer 
relief  than  a  small  one.    Pain  is  also  relieved  by  vomiting,  the  tak- 
ing of  alkalies,  by  rest,  diet  and  opiates, 
(g) — yomiting  occurs  in  more  than  two-thirds  of  instances;  vomitus  usu- 
ally comes  on  at  the  height  of  gastric  distress  and  when  acidity  is 
highest.    Vomitus  of  food  that  has  lain  in  the  stomach  longer  than 
six  hours  ("delayed  vomit")  increases  as  complications  (stenoses 
or  perforation)    develop.     Pyrosis,  water-brash,   eructations   and 
sour  belching  are  common  on  ordinary  diet, 
(h) — Hemorrhage   fhematemesis  or  melenaj   occurs  in  from  30  to  40  per 
cent,    of  instances.     While  hematemesis   is   more   frequent   than 
melena,  yet  melena  alone  may  occur  wholly  irrespective  of  the 
location  of  the  gastric  ulcer.     Severe  hemorrhage  is  accompanied 
by  signs  of  shock  and  collapse. 


454  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

II. — Facts  elicited  upon  examination. 

(a) — Patient  usually  well  nourished  without  toxic  or  cachectic  appearance, 

unless  pyloric  stenosis  or  ' "  hour-glass ' '  contraction  have  occurred. 

(b) — Average  hemoglohm  about  80  per  cent,  unless  severe  hemorrhage 

has  recently  taken  place. 
(c) — Area  of  epigastric  tenderness  in  region  of  pjdoric  half  of  stomach. 
This  is  usually  in  the  mid-epigastrium  but  not  necessarily  so.    The 
area  is  most  frequently  definitely  local  where  acute  or  chronic 
perforation  has  taken  place.     A  tender  ridge  may  sometimes  be 
palpated  where  a  large  chronic  ulcer  exists, 
(d) — Dilated,  splashy  stomach  occurs  where  marked  pylorospasm  exists 
or  stenosis  has  taken  place.     If  this  is  excessive,  visible  peristal- 
sis (and  rarely,  "reverse"  peristalsis)  may  be  noted. 
III. — Facts  elicited  by  laboratory  examination. 
(a) — Test-meal — Motility   interfered  with   in  more   than  50  per   cent,   of 
instances.     Gastric  acidity  increased  with  regard  to  free  hydro- 
chloric acid  in  the  majority  of  non-stenosing  ulcers.     In  stenosing 
ulcers,  with  dilatation  of  the  stomach,  while  free  hydrochloric  acid- 
ity may  not  be  above  normal,   the  total  acidity  is  increased  in 
greater  ratio.    Blood  may  or  may  not  be  present  in  gastric  extracts 
(macroscopically  or  by  chemical  test).    Lactic  acid  is  a  rare  find- 
ing.   Pepsin  and  rennin  are  frequently  increased. 

Microscapically  where  gastric  dilatation  has  occurred,  fermen- 
tative changes  are  proved  by  the  finding  of  great  numbers  of  bud- 
ding yeasts  and  of  sarcinae  (large  and  small  types)  together  with 
remnaiits  of  retained  food, 
(b) — Stool  may  show  nothing  pathologic.  Recent  hemorrhages  generally 
result  in  the  passage  of  "tarry"  stools  for  several  succeeding 
days.  Perforation  of  an  ulcer  to  the  pancreas  not  infrequently 
results  in  pancreatic  inefficiency  with  passage  of  stools  containing 
undigested  food. 

During  periods  of  the  ulcer's  activity,  if  the  patient  is  kept  upon 
meat-free  or  milk  diet  for  several  days,  at  the  end  of  such  time  the 
stool  may  be  shown  by  chemical  tests    (benzidin  or  guaiac)    to 
contain  blood.    Progressive  ulcers  or  ulcers  undergoing  cancerous 
•    change  generally  show  blood  constantly  in  the  stools  by  chemic 
tests. 
(c) — X-ray  findings.    In  many  instances  of  uncomplicated  ulcer  no  facts 
are  returned  after  most  careful  examination  by  both  fluoroscopic 
or  plate  methods.  Complicated  ulcers  (stenosing,  calloused,  "hour- 
glass" producing,  perforating,  etc.),  are  recognizable  in  nearly 
three   out   of  four  instances  by  the   combined  screen  and  plate 
methods. 
A  dependable  clinical  technique  is  as  follows : 

Empty  the  gastro-intestinal  canal  by  the  administration  of  two  ounces  of 
castor  oil  in  beer  or  malt  extract. 

Give  a  motor  opaque  meal,  consisting  of  two  to  four  ounces  of  barium  sul- 
phate (pure)  or  of  bismuth  subcarbonate  in  eight  to  ten  ounces  of  cream  of 
wheat,  oatmeal,  wheatena  or  the  like  at  4  A.  M. 

Six  hours  following  examine  by  means  of  the  fluoroscopic  screen  to  locate 
the  position  of  the  motor  meal.  The  presence  of  the  opaque  mixture  in  the 
stomach  usually  indicates  anatomic  interference  with  the  onward  progress 
of  the  food  or  furnishes  evidence  of  gastric  atony.  Plates  may  be  made  at  this 
time  for  purposes  of  recording  the  position  of  the  motor  meal. 

A  second  meal   for  purposes   of  studying   gastro-duodenal  contour  and 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      45^ 


X-Eay  op  Gastric  Ulcer. 


Eadiogram  showing  clironic  perforating  gastric  ulcer   (A)   with  bismuth  in  crater. 
Base  of  ulcer  was  adherent  to  the  spleen;  ulcer  was  malignant. 


456 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


X-Ray  of  Stomach  After  GASTRO-ENTEROSTOiiy. 

Radiogram  of  stomach  showing  patent  gastro-euterostomy  opening   (greater  curve) 
and  closed  pylorus. 


I 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  457 


-   X-Eat  of  Gastric  Ulcer. 
Eadiogram  showing  perforating  ulcer  on  the  lesser  curvature  near  the  pylorus. 


458      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


X-Kay  of  Stomach  Cancer. 


Eadiogram  showing  extensive  involvement  of  the  stomach  with  cancer.    Note  small  gastric 
lumen,  irregular  outline  and  malignant  "hour-glass"  stenosis  at  A. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  459 

activity  is  next  given.  This  consists  of  two  to  four  ounces  of  barium  sulphate 
or  of  bismuth  subcarbonate  in  sixteen  to  twenty-four  ounces  of  buttermilk, 
fermalac  or  potato  puree. 

While  the  patient  is  taking  this  second  meal,  the  stomach  is  observed  by 
means  of  the  tiuoroscope.  Palpation  is  carried  on  and  the  patient  examined 
in  various  positions.  If  suspicious  contractures,  peristaltic  waves  or  other 
abnormalities  appear,  the  patient  should  be  re-examined  on  several  succes- 
sive days,  before  and  after  the  administration  of  such  anti-spasmodics  as 
atropin  (gr.  1/50  per  hypo.)  or  tr.  of  belladonna  (gtt.  no.  xv. — every  three 
hours  for  a  day).  This  procedure  aids  in  demonstrating  the  constancy  or  the 
transience  of  a  local  sign.  Plates  (frequently  taken  with  the  patient  in  difter- 
ent  positions)  may  be  next  made  for  purposes  of  leisurely  studying  or  for 
^  permanent  record  of  positive  or  negative  results. 

In  brief  the  X-ray  finding's  in  gastric  ulcer  are  :  (1) — Positive  signs,  (a) — 
The  "niche"  or  "accessory  cavity,"  indicating  calloused,  penetrating  ulcer. 
(2) — Corroborative  signs,  (a)  "Incisura, "  i.e.,  local  evidence  of  halting 
of  peristaltic  rhythm  by  s|)astic  contraction  of  circular  muscle  fibres  in  the  vi- 
cinity of  an  ulcer.  Best  brought  out  on  screen  examination  during  or  after 
palpation,  (b) — "Hour-glass"  stomach.  (Bi-loculation).  This  may  be  per- 
manent (callous  ulcer,  perforation,  adhesion)  or  transient  (local  spasm,  with 
or  without  ulcer)  ;  it  should  always  be  proved  by  repeated  examination  with 
and  without  an  antispasmodic  (atropine,  belladonna),  (c) — Gastric  residue. 
This  may  vary  in  amount.  Its  constant  demonstration  after  six  hours  means 
atony  or  stenosis.  Intermittently  it  may  result  from  extra-gastric  or  gastric 
pathology  causing  pyloric  spasm,  (d) — Fixation  of  all  or  part  of  the  stomach 
(perforation,  adhesion-fistula),  (e) — Area  of  tenderness  to  palpation,  usually 
localized  at  some  part  of  the  stomach  shadow.  Should  always  be  checked 
by  repeated  examination  before  and  after  an  anti-spasmodic,  (f) — Altera- 
tions in  gastric  peristalsis,  e.g.,  exaggerated  peristalsis,  intermittent,  fre- 
quently associated  with  spasmodic  closure  and  relaxation  of  the  pylorus.  Anti- 
peristalsis  may  be  seen  on  rare  occasions. 

The  interesting  and  valuable  work  by  Cannon  during  the  past  ten  years 
should  be  studied  by  every  surgeon  to  obtain  a  correct  idea  of  the  mechanics 
of  digestion. 

It  is  only  by  a  just  comprehension  of  the  physiological  processes  of  the 
entire  act  of  food  digestion  that  one  can  safely  undertake  operative  interfer- 
ence therewith. 

It  is  plain  that  this  normal  arrangement  must  be  of  great  value  and  that 
any  surgical  operation  which  interferes  with  any  portion  of  this  machine  must 
leave  the  digestive  apparatus  seriously  reduced  in  efficiency  when  compared 
with  the  normal.  From  this  fact  it  is  but  logical  to  conclude  that  in  any  case 
of  ulcer  of  the  stomach  or  duodenum  the  patient's  digestive  apparatus  will  be 
in  a  vastly  better  condition  to  perform  its  physiological  functions  if  it  can  be 
restored  to  normal  without  surgical  interference.  In  the  early  stages  of  gas- 
tric or  duodenal  ulcers,  experience  has  shown  that  this  is  possible  in  a  large 
majority  of  cases  if  dietetic,  hygienic  and  medicinal  methods  are  carefully  and 
persistently  employed.  Experience  has  also  shown  that  many  of  these  cases 
do  not  remain  permanently  cured  but  that  they  suffer  from  relapses  usuallj^ 
more  severe  than  the  primary  attack,  and  that  after  several  of  these  "cures" 
and  subsequent  relapses  many  ultimately  are  compelled  to  seek  relief  by  sur- 
gical operations.  This  may  be  explained  by  the  theory  that  they  were  only 
apparently  and  not  really  cured,  or  that  they  were  really  cured  and  that  later 
the  same  conditions  which  originally  caused  the  ulcer  to  appear  have  given 
rise  to  the  recurrence. 

A  careful  study  of  the  history  usually  brings  out  the  fact  that  these  patients 


460      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

have  subjected  their  stomachs  to  dietetic  abuses,  that  they  have  lived  under  bad 
hygienic  conditions  as  regards  work,  rest  and  regular  habits  of  life,  and  that 
they  have  not  given  proper  attention  to  their  general  health,  and,  as  Futterer 
claims,  become  anemic  as  a  result  of  these  abuses. 

On  the  other  hand,  with  continued  control  of  the  hygienic  and  dietetic  in- 
fluences b}'  a  physician  for  a  long  period  of  time,  it  is  commonly  possible  to 
train  the  patient  so  that  he  will  acquire  such  habits  of  diet  and  hygiene  as 
will  prevent  the  recurrence  of  an  ulcer  after  it  has  once  healed. 

These  injunctions  are  less  burdensome  to  the  patient  when  he  knows  that 
even  after  operative  treatment  he  would  still  be  compelled  to  observe  more 
or  less  rigid  precautions. 

ACUTE  ULCER  OF  THE  STOMACH 

In  acute  ulcer  of  the  stomach  there  are  usually  two  very  definite  symptoms. 
The  first,  most  constant  symptom,  is  pain,  which  is  located,  as  a  rule,  about 
half  way  between  the  ensiform  appendix  of  the  sternum  and  the  umbilicus. 
This  pain  is  at  first  intermittent  and  occurs  only  after  some  indiscretion  in 
diet.  During  this  stage  pain  can  be  elicited  upon  pressure,  regardless  of 
whether  the  stomach  be  disturbed  with  food  or  not. 

In  the  second  place  there  is  usually  some  hemorrhage.  This  may  be  so 
slight  that  the  blood  can  be  detected  only  upon  careful  examination  of  the 
stools,  or  it  may  be  so  profuse  as  to  give  the  stools  a  characteristic  appear- 
ance, or  it  may  be  so  severe  as  to  cause  nausea  and  vomiting,  in  which  case 
blood  will  appear  in  the  vomitus.  The  blood  lost  may  be  so  considerable  that 
the  patient  will  show  marked  anemia  within  a  few  days ;  but  this  symptom 
usually  disappears  in  a  short  time  if  the  hemorrhage  subsides. 

As  a  rule  rather  severe  gastric  hemorrhage  does  not  require  immediate 
operation.  In  nearly  all  of  these  cases  the  hemorrhage  will  cease  if  the 
patient  is  kept  absolutely  quiet  and  no  food  or  cathartics  are  given  by  mouth. 

These  patients  will  stand  operation  much  better  after  they  have  recovered 
from  their  loss  of  blood.  The  starvation  should  be  continued  for  a  number  of 
daj'S,  for  if  a  small  amount  of  food  is  given  before  the  patient  has  full}'  recov- 
ered, the  distension  of  the  stomach  is  likely  to  reopen  the  bleeding  vessel, 
and  the  more  often  this  occurs,  the  more  anemic  the  patient  becomes.  With 
increasing  anemia,  the  coagulability  of  the  blood  decreases,  and  this  in  itself 
increases  the  likelihood  of  subsequent  hemorrhages.  In  the  meantime  one 
ounce  of  a  commercial  predigested  food  dissolved  in  three  ounces  of  normal 
salt  solution  should  be  given  by  rectum  by  the  drop  method  every  three  hours, 
also  a  sufficient  amount  of  warm  water  should  be  given  in  the  same  manner 
by  rectum  to  overcome  thirst.  When  feeding  by  mouth  is  begun  only  very 
small  quantities  of  milk  with  milk  of  magnesia  should  be  given  ever}'  two 
hours  beginning  with  one  ounce  of  the  former  and  one  half  drachm  of  the 
latter  and  increasing  gradually. 

CHRONIC  ULCER  OF  THE  STOMACH 

Clinical  observation  seems  to  show  that  only  a  small  proportion  of  acute 
ulcers  of  the  stomach  progress,  either  continuously  or  by  interruption,  until 
they  become  chronic.  The  ulcer,  after  its  first  appearance,  may  go  on  causing 
symptoms  until  the  condition  may  rightly  be  termed  chronic.  These  symptoms 
may  vary  in  severity  during  this  period,  or  they  may  continue  at  the  same 
degree  of  severity,  or  there  may  be  a  complete  interruption  of  the  symptoms 
so  that  both  the  patient  and  the  physician  may  reasonably  suppose  that  the 
ulcer  is  permanently  healed.     The  recurrence  may  be  brought  about  by  some 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  461 

indiscretion  in  diet,  by  unfavorable  hygienic  conditions,  or  by  overwork.  A 
rather  common  exciting  cause  is  indigestion  from  overwork,  which  causes  a 
general  neurotic  state. 

The  chief  symptoms  of  chronic  ulcer  of  the  stomach  are :  first,  pain ;  second, 
obstruction  to  the  passage  of  food ;  third,  hemorrhage ;  fourth,  malnutrition. 

The. usual  location  of  pain,  as  before  said,  is  at  a  point  half  way  between 
the  ensiform  appendix  of  the  sternum  and  the  umbilicus.  This  pain  is  in- 
creased upon  pressure ;  it  is  usually  increased  upon  taking  certain  articles 
of  food.  If  the  ulcer  is  located  in  the  lesser  curvature  of  the  stomach,  to  the 
left  of  its  center,  the  pain  is  referred  to  a  point  a  little  below  the  center  of 
the  sternum,  and  pain  at  this  point  is  felt  if  pressure  is  made  over  the  upper 
portion  of  the  abdomen.  If  the  ulcer  is  located  in  the  pyloric  end  of  the 
stomach,  but  does  not  involve  the  pylorus,  the  pain  is  usually  increased  soon 
after  taking  food,  and  the  greatest  point  of  tenderness  is  apt  to  be  in  mid- 
epigastrium.  If  the  ulcer  involves  the  pylorus  or  extends  into  the  duodenal 
side,  there  is  usually  a  very  clear-cut,  definite  train  of  symptoms,  which  are 
the  same  as  those  of  duodenal  ulcer.  Earl}^  in  the  history  of  these  cases  the 
appetite  remains  good,  there  is  no  loss  of  weight  and  the  taking  of  food  brings 
immediate  relief  to  all  symptoms.  The  burning  pain,  the  eructation  of  sour 
gas,  return  in  from  one  to  four  hours  after  eating.  Many  of  these  patients 
suffer  from  nausea  and  vomiting,  which  also  returns  with  the  other  symptoms. 
As  a  rule  the  heartier  the  meal  the  more  marked  and  prolonged  the  relief. 
It  is  very  common  for  these  patients  to  awaken  during  the  night  with  a  severe 
burning  pain  in  the  stomach,  which  is  relieved  by  taking  a  glass  of  milk  or 
other  food.  Early  in  the  disease  these  symptoms  are  periodic  and  alternate 
with  complete  freedom  of  symptoms.  Later  on  after  many  attacks  the  patients 
have  the  same  characteristic  symptoms  but  they  are  less  definite.  The  attacks 
are  more  severe  and  continue  for  a  longer  time ;  the  appetite  may  fail  or  the 
patient  may  be  afraid  to  eat  on  account  of  the  pain,  gas  and  sour  eructation ; 
food  and  drinks  give  relief,  but  the  time  of  relief  is  shortened.  Relief  may 
also  come  from  vomiting,  irrigation  and  alkalies,  but  the  pain  recurs  when 
the  acid  contents  of  the  stomach  return. 

The  characteristic  point  is  the  time  the  symptoms  appear,  and  their  regu- 
larity after  meals,  and  the  relief  which  comes  from  taking  food,  or  by  vomit- 
ing or  irrigation.  Anything  that  will  reduce  the  acidity  below  the  concentra- 
tion necessary  to  irritate  the  ulcer  will  stop  the  pain ;  hence  the  benefit  of  giv- 
ing alkalinized  milk  every  two  hours  during  the  day  and  an  alkaline  mixture 
repeatedly  during  the  night. 

Later  when  complications  arise  the  symptoms  may  change.  Food  may 
not  give  relief  but  is  apt  to  increase  the  pain,  which  is  often  nearly  continu- 
ous. In  these  chronic  cases  it  is  the  early  part  of  the  history  which  is  most 
apt  to  lead  us  to  a  correct  diagnosis. 

Dilatation.  Dilatation  of  the  stomach  is  a  late  symptom  of  gastric  ulcer. 
It  is  caused  by  the  obstruction  which  the  ulcer  itself  offers  in  the  pyloric 
channel,  or  by  the  cicatricial  contraction  which  results  from  partial  or  com- 
plete healing  of  the  ulcer. 

Hyperacidity.  In  chronic  ulcer  of  the  stomach  hyperacidity  is  usually 
present,  and  in  duodenal  ulcer  acids  are  practically  always  very  high.  It  has 
frequentlj^  been  claimed  that  the  presence  or  absence  of  free  hydrochloric 
acid  in  the  stomach,  and  the  presence  of  lactic  acid,  can  be  used  in  making  a 
differential  diagnosis  between  chronic  ulcer  and  carcinoma  of  the  stomach. 
This  method  is  not  to  be  relied  upon  as  its  employment  is  apt  to  lead  to  serious 
mistakes.  Extensive  observations  by  different  investigators  have  proven  that 
free  hydrochloric  acid  is  absent  from  the  stomach  contents  in  a  large  propor- 
tion of  normal  stomachs  in  persons  over  sixty  years  of  age.     Again  in  early 


462      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

carcinoma  the  acids  are  apt  to  be  high  and  only  go  down  after  tliere  is  marked 
stasis  of  the  stomach  contents  from  obstruction  during  the  later  stages  of  the 
disease. 

Perforated  gastric  or  duodenal  ulcer.  A  perforation  may  take  place  in 
either  the  acute  or  chronic  form  of  gastric  and  duodenal  ulcers.  Formerly 
it  was  thought  that  a  perforation  of  a  duodenal  ulcer  was  extremely  rare. 
There  is  no  doubt  but  that  in  the  past  many  perforated  duodenal  ulcers  oc- 
curred and  resulted  in  diffuse  septic  peritonitis  and  the  appendix  was  blamed 
for  the  peritonitis.  This  supposition  seems  reasonable  because  recently  a  far 
greater  percentage  of  perforated  duodenal  ulcers  have  been  encountered  than 
was  formerly  supposed  to  exist.  Occasionally  in  both  the  duodenal  and  gastric 
ulcers  the  perforation  occurs  without  any  previous  symptoms,  but  usually  a 
definite  ulcer  history  can  be  elicited  previous  to  the  symptom^  of  perforation. 
Then  the  patient  suffers  from  a  very  severe  acute  attack  which  usually  follows 
some  pronounced  physical  exertion.  Occasionally  the  attack  comes  on  after 
some  indiscretion  in  diet,  and  only  rarely  does  it  occur  without  any  apparent , 
exciting  cause.  The  patient  suffers  from  a  very  acute  pain  in  the  upper  por- 
tion of  the  abdomen  and  the  pain  is  usually  described  as  coming  on  with  a 
feeling  as  though  something  had  ruptured.  There  is  early  nausea  and  usually 
vomiting  of  stomach  contents,  which  may  or  may  not  be  mixed  with  blood. 
The  abdominal  muscles  immediately  become  tense  and  there  is  a  condition  of 
shock.  Physical  examination  elicits  a  rigid  condition  of  all  of  the  abdominal 
muscles,  and  especially  those  of  the  upper  half  of  the  abdomen.  There  is 
marked  tenderness  upon  pressure  in  the  epigastrium  and  usually,  but  not 
always,  an  absence  of  liver  dullness. 

The  pulse  becomes  rapid  and  thready.  Early  there  is  no  rise  of  tempera- 
ture, but  this  comes  on  with  the  progress  of  the  peritoneal  infection.  If  the 
condition  is  not  diagnosed  and  relieved  early,  the  symptoms  become  those  of 
a  peritonitis. 

Treatment  of  perforated  gastric  and  duodenal  ulcers.  Immediate  opera- 
tion is  always  indicated  provided  the  patient  comes  under  observation  during 
the  first  twelve  hours  after  the  perforation  has  taken  place.  Statistics  show 
that  the  mortality  in  these  cases  is  about  twenty-eight  per  cent.,  while  in  cases 
which  come  under  observation  twenty-four  hours  or  more  after  perforation 
has  taken  place  it  is  more  than  three  times  as  great.  In  these  latter  classes  the 
method  of  treatment  must  depend  upon  the  judgment  of  the  surgeon.  If  the 
condition  present  indicates  that  the  leakage  has  not  been  great,  or  the  prob- 
ability of  the  opening  being  closed  by  a  plug  of  omentum  or  by  the  presence 
of  other  adhesions,  it  may  be  wise  to  place  the  patient  upon  exclusive  rectal 
feeding  until  a  circumscribed  abscess  has  been  formed,  Avhich  abscess  may  then 
be  drained. 

In  the  early  cases  the  operation  should  be  performed  immediately  and 
without  any  preliminary  preparation.  The  incision  should  be  free  and  in  the 
mid-line.  As  soon  as  the  abdomen  is  opened  an  immediate  search  for  the  per- 
foration should  be  made.  This  should  be  carried  out  in  a  systematic  manner 
so  that  the  tissues  will  not  be  handled  any  more  than  necessary. 

As  soon  as  the  perforation  is  found  it  is  grasped  and  held  closed  temporar- 
ily by  an  assistant,  while  the  surgeon  carefully  sponsres  all  of  the  soiled  areas 
to  remove  as  much  of  the  stomach  contents  as  possible,  great  care  being  used 
to  cause  little  or  no  traumatism  to  the  peritoneum.  The  remaining  portion  is 
now  shut  off  from  the  field  of  operation  by  the  placing  of  some  large  gauze 
pads  in  the  abdominal  cavity.  A  stomach  tube  is  now  introduced  and  gastric 
lavage  carried  out  until  the  water  returns  perfectly  clear.  The  perforation 
should  now  be  closed  and  in  doing  this  care  should  be  used  so  that  the  stomach 
will  be  left  free  from  any  deformity  which  may  later  cause  an  obstruction. 


I 
i 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


463 


X-Eay  of  Stomach  Cancer. 

Eadiogram   showing   general  gastric   carcinoma.     Note   vei'y   irregular   gastric   outline 
due  to  intrusion  of  tumor  upon  gastric  lumen;  large  mass  to  pyloric  side  of  A, 


464      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

As  a  rule  the  hemorrhage  has  ceased  by  the  time  the  operation  is  performed 
so  it  is  not  necessary  to  give  any  attention  to  this  part  of  the  condition. 

The  opening  in  the  stomach  is  sutured  by  placing  a  row  of  Connell  sutures, 
covered  by  a  second  row  of  Lembert  stitches.  The  row  of  sutures  should  be 
placed  at  right-angles  to  the  long  axis  of  the  stomach  to  prevent  a  narrowing 
which  might  later  cause  an  obstruction. 

Thorough  drainage  should  be  established. 

If  there  has  been  an  extensive  extravasation  of  stomach  contents,  a  second 
incision  should  be  made  just  above  the  symphysis  pubis  and  a  drain  carried 
down  into  the  cul-de-sac,  while  the  upper  portion  of  the  abdominal  cavity 
should  be  drained  through  the  upper  angle  of  the  original  incision. 

If  the  perforation  has  taken  place  at  or  near  the  pylorus  one  may  expect 
a  certain  amount  of  obstruction  to  follow  and  it  may  become  necessary  to 
perform  a  gastro-enterostomy  for  relief  of  same. 

It  is  rarely  necessary  or  wise  to  perform  a  gastro-enterostomy  at  the 
time  of  closing  an  acute  perforation  of  the  stomach,  because  the  additional 
time  and  manipulation  are  apt  to  increase  the  gravity  of  the  prognosis. 

Treatment  of  chronic  gastric  ulcer.  There  are  many  cases  in  which  a  per- 
manent cure  is  not  possible  although  they  have  received  most  careful  dietetic, 
hygienic  and  medicinal  treatment.  In  any  given  case  the  sooner  this  fact 
becomes  established  the  better,  in  order  that  the  operation  may  be  performed 
before  one  or  the  other  of  the  various  unfortunate  complications  may  have 
arisen. 

The  most  serious  complications  to  be  considered  are  (1)  perforation,  (2) 
hemorrhage,  acute  or  chronic;  (3)  emaciation;  (4)  adhesion  to  surrounding 
structures;  (5)  the  implantation  of  carcinoma. 

Besides  these  serious  complications  which  are  apt  to  occur  a  number  of 
physiological  and  anatomical   changes  develop  quite  constantly. 

Secretion  of  mucus.  In  order  to  protect  the  ulcer  from  the  irritating  gastric 
juice  a  large  amount  of  mucus  is  secreted.  At  the  same  time  there  is  a  con- 
traction of  the  muscles  in  the  region  of  the  pylorus  to  establish  a  condition] 
of  physiological  rest.  Many  of  these  patients  do  very  w^ell  if  placed  upon  an 
exclusive  liquid  diet,  because  with  this  neither  the  presence  of  mucus  nor  the 
contraction  of  the  muscles  does  any  harm,  especially  if  the  gastric  juice  is  kept 
alkaline  by  proper  remedies ;  and.  if  milk  is  given,  it  is  medicated  so  that  it 
will  not  form  coagula. 

It  is  quite  difiPerent  with  solid  food,  as  on  the  one  hand  this  will  be  rendered 
much  more  indigestible  by  being  covered  with  mucus,  while  the  obstruction 
caused  by  the  contraction  of  the  muscles  in  the  pyloric  end  of  the  stomach 
interferes  with  the  passage  of  the  food  into  the  small  intestine. 

Hypertrophy  of  gastric  muscles.  To  overcome  the  former  difficultv  a  great  i 
amount  of  hydrochloric  acid  is  secreted,  while  to  correct  the  latter  there  is  a] 
compensatory  hypertrophy  of  the  muscles  of  the  stomach. 

Of  course  the  hyperacidity  of  the  srastric  juice  increases  the  irritation  of 
the  ulcer,  and  the  muscle  hypertrophy  increases  the  traumatism,  consequently 
both  of  these  changes  are  likely  to  do  much  more  harm  than  good. 

If  the  ulcer  has  healed,  in  the  meantime,  all  may  still  be  well,  but  if  this 
has  not  occurred,  conditions  are  practically  certain  to  go  from  bad  to  worse" 
until  relieved  by  surgical  intervention.  Meanwhile,  the  following  changes 
may  have  occurred  in  the  ulcer  itself;  it  may  have  encroached  upon  somej 
blood  vessel  of  considerable  size  causing  dangerous  hemorrhage;  it  may 
have  advanced  to  a  point  dangerously  near  to  perforation,  causing  adhesions! 
to  other  organs,  or  a  perforation  into  one  of  these  organs,  viz.:  the  pancreas,^ 
liver,  spleen,  omentum  or  the  duodenum,  or  into  the  abdominal  wall  may  have^ 
t?^ken  place.    "We  have  personally  encountered  all  of  tl^ese  coiiditions, 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


465 


The  ulcer  may  have  perforated  into  the  free  abdominal  cavity,  or  a  car- 
cinoma may  have  been  implanted  upon  the  ulcer. 

The  most  common  course,  however,  results  in  an  obstruction  at  the  p^doric 
end  which  may  be  due  to  an  extensive  induration  at  the  base  of  the  ulcer,  to  a 


rr-r^"-'^ 


•^.K^pp'^^r 


Gastro-exterostomt. 

Mayo-Moynihan  method  of  gastro-enterostomy,  showing  lowest  portion  of  posterior  wall 
of  stomach  brought  through  a  tear  in  the  mesentery  of  the  transverse  colon,  and  the  points 
on  the  stomach  and  jejunum  selected  for  the  anastomosis. 

cicatricial  contraction  as  a  result  of  the  healing  of  the  ulcer,  or  to  a  spasmodic 
contraction  of  the  pyloric  sphincter.  This  obstruction,  as  has  been  stated 
above,  will  be  overcome  for  a  time  by  the  compensatory  hji^ertrophy  of  the 
muscles  of  the  stomach  but  if  not  relieved  this  will  invariably  be  followed 
by  an  exhaustion  of  the  muscles  and  a  consequent  gastric  dilatation.     This 


466 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


dilatation  may  be  moderate  in  degree  or  it  may  be  excessive.    We  have  seen 
the  lower  edge  of  the  stomach  resting  in  the  pelvis  of  the  patient. 

In  the  presence  of  marked  dilatation,  there  always  remain  portions  of 
food  in  the  stomach  and  this  residual  food  invariably  decomposes  so  that  the 
patient  is  forced  to  absorb  products  of  decomposition  instead  of  products  of 
normal  digestion.     All  fresh  food  placed  in  the  stomach  is  at  once  contam- 


Gastro-enterostomy. 

Mayo-Moynihan  method  of  gastro-enterostomy,  showing  forceps  holding  the  stomach  and 
jejunum  in  position  for  suture. 

inated  by  the  decomposing  fluid.  This  condition  accounts  for  the  emaciation 
or  cachexia  which  is  invariably  present  in  advanced  cases  of  this  kind.  The 
marked  improvement  often  following  the  systematic  use  of  gastric  lavage  is 
easily  explained  when  one  takes  into  consideration  the  above  conditions. 

It  is,  of  course,  best  not  to  delay  until  this  extreme  development  before 
relieving  the  patient  through  surgical  means. 

Relief  in  these  cases  must  come  by  supplying  drainage.  It  has  been  shown 
by  a  very  large  clinical  experience  that  with  efficient  drainage  of  the  stomach, 
by  way  of  a  properly  executed  gastro-enterostomy,  better  conditions  may  be 
established  for  the  patient  than  by  any  other  present  method  of  treatment. 

Such  results  will  vary  not  only  with  the  skill  of  the  operator  but,  also,  as 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      467 

regards  their  permanency,  with  the  care  with  which  these  patients   avoid 
hygienic  and  dietetic  abuses  after  recovering  from  the  operation. 

The  treatment  of  duodenal  ulcer  is  the  same  as  that  for  gastric  ulcer. 

GASTRO-ENTEROSTOMY 

Gastro-enterostomy  may  be  performed  for  the  following  conditions :  First, 
for  relief  of  obstruction  of  the  pylorus ;  second,  for  the  purpose  of  relieving 
the  irritation  due  to  the  passage  of  food  over  an  ulcer  in  the  pyloric  end  of 
the  stomach  or  duodenum ;  third,  for  drainage  of  a  greatly  distorted  stomach ; 
fourth,  drainage  of  a  stomach  containing  an  inoperable  carcinoma ;  fifth,  for 
establishing  a  communication  between  the  remnant  of  a  stomach  and  the 
intestine  after  the  pjdoric  end  of  the  stomach  has  been  removed. 

Preparatory  treatment.  In  many  of  these  cases,  not  sufficiently  strong  to 
bear  an  operation  well,  because  of  their  impaired  nutrition,  together  with  the 
anemia  caused  by  the  loss  of  blood,  it  is  wise  to  treat  the  patient  for  a  time 
before  undertaking  the  t)peration.  It  is  well  in  these  cases  to  remove  all  de- 
composing substances  from  the  stomach  and  intestines  by  the  administration 
of  castor  oil,  given  in  the  manner  described  before  in  the  foam  of  beer  or  ex- 
tract of  malt,  in  doses  of  two  ounces.  "We  have  used  this  in  many  cases  and 
have  never  seen  the  slightest  harm  result  from  it,  but  have,  on  the  contrary, 
constantly  observed  great  benefit.  Then  it  is  well  to  permit  the  stomach  to 
rest  completely  for  one  or  two  weeks,  or  even  longer,  and  to  administer  nour- 
ishment by  nutrient  enemata.  Mild  saline  laxatives  may  be  given  by  mouth 
because  this  will  facilitate  the  healing  of  the  gastric  ulcer  and  will  at  the  same 
time  prevent  constipation.  Pure  olive  oil,  given  at  bedtime  in  doses  of  two 
ounces,  seems  to  aid  in  building  up  the  patient  and  at  the  same  time  leave  the 
ulcerated  stomach  without  giving  rise  to  any  irritation. 

If  there  are  no  acute  symptoms  it  is  well  to  cocainize  the  pharynx  well  by 
spraying  it  with  a  four  per  cent,  solution  of  cocain.  The  patient  should  be 
permitted  to  swallow  a  little  of  this  in  order  to  anesthetize  the  esophagus. 
After  waiting  about  four  minutes,  in  order  to  give  the  cocain  an  opportunity 
to  take  efi^ect,  irrigate  the  stomach  thoroughly  with  normal  salt  solution. 

If  there  are  any  symptoms  of  acute  inflammatory  disturbance  in  the  lining 
of  the  stomach  it  is  better  to  avoid  gastric  lavage,  as  this  might  give  rise  to 
hemorrhage  from  an  ulcer. 

It  is  best  not  to  inflate  a  stomach  with  gas  so  long  as  one  suspects  the 
presence  of  an  ulcer,  for  fear  of  perforation,  but  this  is  necessary  in  order  to 
determine  positively  the  extent  of  gastric  dilatation.  It  is  safest  to  insert  a 
stomach  tube  for  the  purpose  of  distending  the  stomach  with  gas,  and  to  attach 
it  to  an  ordinary  rubber  bulb  with  v^hich  air  can  be  pumped  into  the  stomach 
slowly  and  consequently  safely.  After  the  degree  of  dilatation  has  been 
determined  the  gas  may  be  permitted  to  escape  through  the  tube. 

If  the  patient  is  in  fair  physical  condition  the  only  preparatory  treatment 
necessary  is  the  administration .  of  two  ounces  of  castor  oil  the  day  before 
the  operation  and  a  gastric  lavage  the  evening  before,  and  again  on  the  morn- 
ing of  the  operation. 

Incision.  An  incision  about  four  centimeters  to  the  right  of  the  median 
line  will  be  found  most  satisfactory  in  the  majority  of  cases,  so  that  the 
stomach,  duodenum,  gall-bladder  and  appendix  can  all  be  carefully  inspected. 
All  of  these  organs  should  not  only  be  palpated,  but  should  be  inspected  as 
well,  before  it  is  definitely  decided  what  procedure  shall  be  carried  out  in  any 
particular  case. 

During  the  past  few  years  the  authors  have  used  the  Moynihan-Mayo 
method  of  gastro-enterostomy,  which  has  proved  very  satisfactory  indeed. 


468 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


Gastro-enterostomy. 
Mayo-Moynihan  method  of  gastroenterostomy  showing  application  of  first  Lembert  stitch. 


Gastro-enterostomy. 

Mayo-Moynihan  method  of  gastro-enterostomy,  showing  Lembert  stitch  in  place,  the 
incision  made  in  the  stomach  and  jejunum  and  the  second  row  of  stitches  passing  through  all 
the  coats  of  the  stomach  and  intestines. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH  469 

This  operation  contains  the  important  elements  reasonably  to  be  exj)ected  in 
a  gastro-enterostomy.  It  is  simple.  It  places  the  opening  in  the  lowest  part 
of  the  stomach.  It  provides  an  opening  large  enongh  to  prevent  secondary 
obstruction  from  contraction.  It  establishes  an  immediate  communication 
between  the  stomach  and  the  intestine.  It  leaves  the  jejunum  practically  in 
its  normal  position  and  without  any  angulation.  It  leaves  no  loop  to  cause 
intestinal  obstruction.  It  prevents  the  possibility  of  hemorrhage  either  during 
or  after  the  operation.  It  prevents  soiling  of  the  peritoneal  cavity  by  intes- 
tinal or  stomach  contents  during  the  operation. 

The  first  step  of  the  operation  is  to  select  a  point  in  the  stomach  wall  for 
the  anastomosis.  This  point  should  be  made  in  healthy  tissue  a  considerable 
distance  from  the  diseased  area,  if  possible.  In  order  to  insure  the  passage 
of  the  food  permanently  through  the  gastroenterostomy  opening  we  now  fol- 
low the  suggestion  of  Hartman  to  make  the  opening  in  the  stomach  near  its 
pyloric  end.  [ 

It  is  wise  to  choose  the  most  dependent  portion  of  the  stomach  for  this 
purpose,  because  this  will  secure  a  more  perfect  drainage  than  could  be  ac- 
complished in  any  ot^er  way,  the  walls  of  the  stomach  forming  a  kind  of 
funnel  in  which  all  of  the  sides  slope  down  to  the  point  of  anastomosis. 

Mayo  has  pointed  out  the  fact  that  by  doing  this,  it  is  possible  in  almost 
every  case  to  prevent  regurgitant  vomiting  after  gastro-enterostomy. 

The  transverse  colon  is  brought  up  out  of  the  wound  and  its  mesentery 
placed  taut,  and  an  opening  is  torn  in  the  mesocolon  at  a  non-vascular  point 
opposite  the  crossing  of  the  jejunum.  The  posterior  wall  of  the  stomach  is 
brought  out  through  this  opening  and  the  lowest  point  in  the  greater  curva- 
ture of  the  stomach  is  grasped  by  a  pair  of  tenaculum  forceps,  which  would 
be  at  the  point  (a)  in  the  plate.  A  second  pair  of  forceps  should  be  placed 
about  8  cm.  from  the  first  one  in  a  direction  downwards  and  to  the  right,  as  at 
(b)  in  the  plate.  This  makes- the  opening  in  the  stomach  in  normal  direction 
of  the  jejunum  after  it  passes  through  the  mesocolon,  which  is  from  right 
doAvnwards  to  the  left  in  eighty  per  cent,  of  cases,  according  to  Lewis.  In 
the  other  twenty  per  cent,  it  is  from  the  left  downwards  to  the  right.  In  these 
cases  the  opening  should  be  from  left  to  right  in  the  stomach.  As  soon  as  the 
two  forceps,  marking  the  location  and  direction  of  the  opening  in  the  stomach, 
have  been  applied,  the  stomach  wall  lying  between  these  two  forceps  shoidd 
be  grasped  by  a  pair  of  stomach  forceps,  the  blades  of  which  should  be  pro- 
tected by  rubber  tubing,  as  shown.  Care  should  be  used  to  have  a  sufficient 
amount  of  the  stomach  wall  project  beyond  the  blades  of  the  forceps  to  pre- 
vent tension  during  suturing.  The  jejunum  is  next  picked  up,  which  is  found 
by  passing  the  hand  down  along  the  mesocolon  to  a  point  just  to  the  left  of 
the  spine.  The  jejunum  is  now  grasped  on  its  convex  surface  two  to  five 
centimeters  distant  from  the  point  where  the  intestine  passes  through  the 
transverse  mesocolon  at  point  (b'),  and  a  second  8  cm.  distant  at  point 
(a').  This  portion  of  the  intestinal  wall  is  grasped  by  another  pair  of  long- 
bladed  forceps  in  the  same  manner  as  the  stomach  wall,  and  the  two  forceps 
are  placed  side  by  side.  Gauze  pads  are  now  placed  about  the  forceps  pro- 
tecting all  of  the  tissues  except  the  small  portion  of  the  stomach  and  duodenum 
within  the  grasp  of  the  forceps.  The  next  step  consists  in  placing  a  row  of 
Lembert  stitches  uniting  the  stomach  and  jejimum  for  a  distance  of  about  six 
centimeters.  Fine  silk  or  linen  thread  is  usually  used  in  making  this  stitch. 
An  incision  is  now  made  into  the  stomach  about  one-fourth  of  a  centimeter 
distant  from  the  suture  line,  then  a  similar  one  into  the  jejunum.  As  these 
incisions  are  made  any  stomach  and  intestinal  contents  should  be  carefully 
sponged  away  to  avoid  soiling  any  of  the  tissues.     The  openings  just  made 


470 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


Gastro-entkrostomy. 

Mayo-Moynihan  method  of  gastro-enterostomy,  showing  application  of  second  row  of 
stitches' posteriorly,  which  pass  through  the  entire  thickness  of  both  stomach  and  intestinal 
wall. 


Gastro-enterostomy. 


Mayo-Moynihan  method  of  gastro-enterostomy,   showing  application   of  the   deep   row   of 
stitches  anteriorly  passing  through  the  entire  thickness  of  both  the  stomach  and  intestinal  wall. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOjVIACH 


471 


should  be  about  five  centimeters  in  length,  which  is  one  centimeter  shorter 
than  the  first  suture  line. 

A  second  row  of  sutures  consisting  of  a  running  chromicized  catgut  stitch 
is  placed  just  in  front  of  the  Lembert  stitch,  which  passes  through  all  of  the 
coats  of  the  stomach  and  intestine.  This  stitch  controls  the  hemorrhage  and 
approximates  the  cut  edges  behind,  completing  the  posterior  suturing.  The 
suturing  is  now  continued  by  means  of  the  Connell  stitch  which  passes  through 
all  coats  and  effectually  controls  hemorrhage  and  leakage.  The  first  Lembert 
stitch  is  now  continued  forward  approximating  the  peritoneal  surfaces  an- 
teriorly.    This  stitch  completes  the  anastomosis.     (See  plates.) 


GASTRO-EXTEEOSTOilY. 

Mavo-Movnihan  method   of   gastro-euterostomy,   showing   anterior   Lembert   stitch. 

The  opening  in  the  transverse  mesocolon  should  now  be  closed  by  suturing 
its  edges  along  the  line  of  anastomosis.  This  may  be  attached  on  the  jejunal 
side,  or  the  stomach,  or  to  both,  directly  over  the  line  of  suture.  In  doing  this 
care  should  be  used  to  see  that  the  opening  in  the  mesocolon  is  large  enough 
so  there  can  be  no  constriction  which  might  cause  an  obstruction  by  kinking 
the  jejunum. 

Closing  of  the  pylorus.  In  patients  suffering  from  gastric  or  duodenal 
ulcer  who  have  a  \ery  marked  obstruction  to  the  passage  of  food,  good  re- 
sults may  be  expected  from  a  simple  gastro-enterostomy,  as  described  above. 
On  the  other  hand,  in  cases  of  ulcer  in  the  region  of  the  pylorus  or  duodenum 
in  which  there  is  not  much  obstruction,  the  operation  of  gastro-enterostomy  is 
apt  to  give  only  temporary  relief.  In  these  cases  it  is  well  to  close  the  pylorus 
is  some  way  in  addition  to  making  a  gastro-enterostomy.  The  closure  is  best 
accomplished  by  cutting  through  the  stomiach  at  or  near  the  pylorus,  then 
closing  both  the  stomach  and  duodenal  end  with  a  double  row  of  silk  sutures. 


472 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


In  addition  to  closing  the  pylorus,  it  is  often  best  to  make  an  excision  of  the 
pyloric  end  of  the  stomach,  as  advised  by  Rodman.  There  have  been  many 
methods  devised  for  closing  the  pylorus  without  making  a  section  of  the  stom- 
ach or  duodenum.  The  authors  have  found  the  following  to  be  satisfactory : 
A  strip  of  the  deep  fascia  is  cut  from  along  the  edge  of  the  abdominal  incision 
about  one  cm.  wide  and  eight  cm.  long.  The  pylorus  is  now  closed  by  folding 
it  from  side  to  side  b}"  placing  a  few  silk  sutures.  A  pair  of  curved  hemostatic 
forceps  is  passed  behind  the  pylorus.     The  strip  of  fascia  is  grasped  in  the 


/ 


%r^ 


IS 


yi 


J 


b'K^rr'^'-^.a, 


G  ASTRO-ENTEROSTO  M  Y. 

Mayo-Moynilian   metliod   of   gastro-enterostomy.      Operation   completed   showing   relations 
of  stoniacli,  jejunum  and  transverse  colon. 


forceps  and  pulled  through  behind  the  pylorus.  The  forceps  are  again  passed 
behind  the  pylorus,  grasping  the  end  of  the  fascia  strip  a  second  time,  which 
is  drawn  around  the  pylorus  again,  thus  surrounding  the  pylorus  twice  with 
the  strip  of  fascia,  the  ends  of  which  are  now  sutured  together  with  silk 
sutures.  This  makes  a  \Qvy  firm  closure,  and  as  far  as  we  have  been  able  to 
determine  clinically  the  closures  have  been  permanent.  Bartlett  has  recently 
introduced,  as  illustrated  by  the  accompanying  drawings,  a  method  which  has 
been  very  satisfactory  in  his  hands  and  which  seems  very  reasonable  and  safe 
and  promises  to  be  well  worth  trying. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


473 


A. 


B. 


Exclusion  of  Pylorus.     Willard  Bartlett's  Method. 
(Journal  A.  M.  A.,  Aug.  15,  1914.) 

Fig.  A  represents  the  application  of  tlie  special  triple  clamp,  composed  of  a  central  clamp 
provided  with  a  slit  to  either  side  of  which  is  attached  a  crushing  clamp  in  such  a  manner 
that  the  central  clamp  can  be  removed  without  disturbing  the  lateral  crushing,  clamps.  Before 
removing  the  central  clamp  the  stomach  is  cut  two-thirds  of  the  distance  from  the  greater  to 
the  lessor  curvature.     The  triple  clamp  is  applied  to  the  stomach  just  proximal  to  the  pylorus. 

Pig.  B  shows  the  cut  end  of  the  stomach  above  sutured  with  continuous  cat-gut  which 
is  to  be  carried  over  the  other  side  in  the  same  manner,  then  both  forceps  are  removed  and 
the  entire  suture  line,  as  shown  in  Pig.  C  by  means  of  continuous  Lembert  sutures.  The 
sutures  in  Pig.  B  grasp  all  of  the  layers  of  the  stomach  wall,  those  in  Pig.  C  grasp  mucosa, 
museularis  and  submucous  connective  tissue.     The  last  is  the  most  important  of  all  the  layers. 


474      SUEGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

After-treatment  of  gastro-enterostomy.  As  soon  a.s  the  patient  recovers 
from  the  anesthetic  he  should  be  placed  on  a  head  rest  in  a  semi-sitting  posture. 
This  position  favors  drainage  of  mucus  into  the  intestine,  which  may  accumu- 
late in  the  stomach  after  the  operation,  and  also  favors  expulsion  of  gas 
through  the  esophagus.  If  the  patient  suffers  from  nausea  or  vomiting,  gastric 
lavage  should  be  used.  In  doing  this  care  should  be  employed  not  to  distend 
the  stomach.  Not  more  than  half  a  pint  of  water  should  be  allowed  to  run 
into  the  stomach  at  one  time.  If  the  vomiting  recurs,  the  lavage  should  be 
repeated. 

Occasionally,  the  patient  suffers  from  acute  dilatation  of  the  stomach.  This 
condition  may  come  on  suddenly  and  is  characterized  by  a  sense  of  fullness 
and  distension  of  the  upper  portion  of  the  abdomen.  The  breathing  becomes 
labored,  the  heart  very  rapid  and  the  picture  is  one  of  a  very  alarming  state. 
The  condition  can  easih'  be  relieved  by  passing  a  stomach  tube.  Enormous 
quantities  of  gas  will  escape  through  the  tube  and  the  patient  will  obtain 
immediate  relief.  The  pulse  and  breathing  soon  become  normal  and  the  patient 
again  proceeds  in  a  satisfactory^-  manner. 

Feeding.  If  the  patient  is  not  greatly  reduced,  it  is  best  to  feed  per  rectum 
for  three  or  four  days,  and  then  allow  broth,  gruel,  or  buttermilk,  or  some  of 
the  commercial  concentrated  liquid  foods.  In  anemic  patients  the  authors 
have  frequently  allowed  liquid  food  on  the  second  day  with  good  results,  and 
at  the  same  time  administered  salt  solution  and  some  predigested  food  per 
rectum.  The  diet  should  be  carefully  regulated  for  several  months  after  the 
operation  so  that  the  mechanical  and  chemical  functions  of  the  stomach  may 
become  as  near  normal  as  possible  after  the  changed  anatomical  relations 
following  the  operation.  It  is  well  to  employ  the  following  diet  list  whenever 
there  is  any  irritation  following  gastroenterostomy.  This  may  be  used  upon 
occasions  of  gastric  disturbance  for  months  or  years  after  the  operation, 

DIET 

"Take  from  two  to  eight  ounces  of  hot  milk  at  6-8-10-12-2-4-6-8  and  10. 
Later  you  may  take  the  other  articles  of  food  on  this  list  at  8-12  and  6. 

1st  week — Four  pints  of  hot  milk  daily  with  medicine ;  if  this  is  not  suffi- 
cient to  keep  up  your  strength  you  may  add  from  one  to  four  raw  eggs. 

2nd  week — Same  as  1st,  and  two  to  four  raw  or  soft-boiled  eggs  in  addition. 

3rd  week — Same  as  2nd,  and  two  to  six  pieces  of  very  dry  toast  in  addition. 

4th  week — Same  as  3rd,  and  all  kinds  of  milk  or  cream  soup  in  addition. 

5th  week- — ^Same  as  4th,  and  all  kinds  of  mush  or  boiled  rice  in  addition. 

6th  week — Same  as  5th,  and  broiled,  stewed  or  boiled  beef  or  mutton  in 
addition,  chew  and  swallow  the  juice,  but  not  the  fibre. 

Later  add  cooked  vegetables  and  cooked  fruits,  adding  only  one  kind  each 
week. 

Later  you  may  swallow  the  beef  or  the  mutton. 

Even  after  recovering  fully,  do  not  eat  pastrv%  pie,  pancakes,  pickles,  pork 
or  puddings.  No  cake,  candy  or  canned  goods.  No  raw  vegetables  or  raw 
fruits,  unless  the  latter  are  perfectly  ripe  and  not  sour. 

Carefully  cleanse  your  teeth  before  and  after  each  meal. 

Carefully  cleanse  your  tongue  and  throat  by  gargling  before  and  after 
each  meal." 

EXCISION  OF  GASTRIC  ULCER 

Technique.  It  has  at  times  seemed  wise  to  remove  a  gastric  ulcer  radically 
by  excising  it  entire,  and  uniting  the  edges  of  the  wound  in  the  stomach.  This 
is  done  especially  because  it  has  been  long  known  that  gastric  ulcers  are  a 


SUEGERY  OF  THE  ESOPHAGUS  AND  STOI^IACH  475 

predisposing  cause  to  the  development  of  carcinoma.  Usually  tliese  ulcers  do 
not  persist  unless  there  is  an  obstruction  to  the  passage  of  the  food  through 
the  pylorus,  and  if  this  condition  exists  the  excision  of  an  ulcer  would  hardly 
result  in  a  permanent  cure.  Moreover,  the  establishment  of  free  drainage  of 
the  stomach  by  means  of  a  gastro-enterostomy  would  result  in  the  healing  of 
such  an  ulcer.  However,  there  is  a  class  of  ulcers  which  stand  on  the  border 
line  of  malignant  growths,  and  in  this  class  an  excision  of  the  ulcer  and  sur- 
rounding tissues  is  certainly  indicated.  This  can  be  done  most  safely  by 
lifting  up  the  stomach  and  making  an  incision  around  the  ulcer,  first  through 
the  serous  and  muscular  coats,  then  grasping  all  of  the  vessels  with  hemostatic 
forceps  and  ligating  them  with  fine  catgut,  then  lifting  the  wall  of  the  stomach 
so  as  to  have  the  wound  extend  at  right  angles  with  the  long  axis  of  the 
stomach.  The  mucous  membrane  may  now  be  sutured  without  first  cutting  it, 
or  it  may  be  cut  and  then  sutured  with  a  continuous  catgut  or  silk  suture,  the 
first  row  grasping  only  the  muscular  and  mucous  layers.  Over  this  a  con- 
tinuous Lembert  suture  is  applied.  This  suture  grasps  all  of  the  layers  down 
to  the  mucous  membrane,  but  not  through  it.  By  applying  this  row  of  sutures 
transversely  to  the  axis  of  the  stomach  one  avoids  the  tendency  of  narrowing 
the  lumen  of  the  pylorus  in  case  the  ulcer  is  near  the  pyloric  end. 

The  excision  of^an  ulcer  should  not  prevent  the  surgeon  from  making  a 
gastro-entero.stomy  if  this  is  otherwise  indicated,  but  a  portion  of  the  stomach 
must  be  selected  sufficiently  distant  from  the  location  of  the  ulcer  to  insure 
satisfactory"  healing.  Of  course,  the  same  precautions  should  be  taken  in 
making  gastro-enterostomies  in  these  cases  as  in  all  others. 

In  eases  in  which  a  chronic  ulcer  of  the  stomach  co-exists  with  a  stenosis 
of  the  pylorus  sufficiently  small  to  indicate  a  gastro-enterostomy,  it  is  doubtful 
whether  an  excision  of  the  ulcer  is  ever  indicated,  because  the  gastro-enteros- 
tomy will  be  followed  by  a  perfect  drainage  of  the  stomach,  and  this  by  the 
permanent  healing  of  the  gastric  ulcer. 

Rodman  has  suggested  that  in  ulcer  of  the  pyloric  end  of  the  stomach  the 
pyloric  end  be  excised  entirely  to  a  sufficient  distance  beyond  the  ulcer  to 
include  what  he  calls  the  ulcer-bearing  area,  and  then  to  make  a  gastro- 
enterostomy similar  to  that  which  has  been  described.  Aside  from  the  fact 
that  this  method  removes  the  ulcer  radically  it  has  the  further  advantage  of 
removing  the  portion  of  the  stomach  in  which  carcinoma  is  most  likely  to 
occur  secondarily  to  the  existence  of  an  ulcer. 

GASTRO  ENTEROSTOMY    AND    ENTERO-ENTEROSTOMY    WITH    THE 
McGRAW  ELASTIC  LIGATURE 

This  method  has  been  found  very  satisfactory  in  cases  in  which  there  is  not 
a  complete  obstruction  of  the  pylorus.  The  elastic  ligature  does  not  cut  its  way 
out  for  two  or  three  days,  so  there  is  no  drainage  from  this  source  during  that 
time.  If  the  obstruction  of  the  pylorus  is  complete,  there  is  apt  to  be  an 
accumulation  of  fluid  in  the  viscus  which  cannot  pass  on  until  the  elastic  cord 
has  established  a  communication  between  the  stomach  and  the  jejunum. 

The  immediate  results  have  been  characterized  by  an  absence  of  shock  and 
discomfort  following  the  operation  and  there  has  been  no  regurgitant  vomit- 
ing, vicious  circle  after  gastro-enterostomy.  the  anterior  operation  having  been 
employed  invariably  and  the  lowest  point  having  been  chosen,  the  anastomosis 
being  made  directly  above  the  gastro-epiploic  artery. 

Technique.  In  gastro-enterostomy  the  following  steps  are  taken :  The  ab- 
domen is  opened  in  the  usual  manner. 

The  transverse  colon  and  the  omentum  are  then  drawn  out  through  the 
incision  and  the  jejunum  is  located  a  little  to  the  left  of  the  median  line,  just 


476 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


where  it  passes  through  the  mesentery  of  the  colon.    By  lifting  up  the  colon  one 
can  always  easily  locate  this  intestine. 

It  is  preferable  to  make  a  posterior  gastro-enterostomj-  through  a  tear  in 
the  transverse  mesocolon,  the  beginning  of  the  jejunum  being  united  to  the 
lowest  portion  of  the  stomach.  The  points  of  anastomosis  on  the  stomach  and 
the  jejunum  are  selected  just  the  same  as  described  in  the  Mayo-Moynihan 


Enterostomy  with  McGraw  Elastic  Ligature. 

The  primary  Lembert  suture  in  place. 
(From  Dr.  H.  O.  "Walker's  original  drawing  of  Dr.  Theodor  McGraw'^  operation.) 


operation  previously  mentioned.     The  jejunum  and  stomach  are  sutured  to- 
gether with  a  running  Lembert  stitch  for  a  distance  of  seven  centimeters. 

A  long  needle  armed  with  a  McGraw  elastic  ligature  is  then  passed  into  the 
lumen  of  the  intestine,  so  that  its  points  of  entrance  and  exit  are  one-half  cm. 
within  the  line  of  sutures  at  each  end.  The  point  of  the  needle  is  grasped  with 
forceps,  then  the  elastic  ligature  is  stretched  in  order  to  decrease  its  caliber 
so  that  it  will  thoroughly  fill  the  needle  holes  in  the  intestine  when  it  is  re- 
laxed after  being  drawn  through.     The  same  step  is  reversed  in  the  stomach. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


477 


A  strong  silk  ligature  is  then  placed  between  the  two  free  ends  of  the  elastic 
ligature,  which  are  then  tied  in  a  half  knot.  While  these  ends  are  drawn  very 
tightly  the  silk  ligature  is  tied  down  upon  them  where  they  are  crossed.  It  is 
well  to  tie  a  triple  knot  in  the  silk  ligature  to  insure  against  slipping.  When 
the  elastic  ligature  is  relaxed  it  forms  a  little  enlargement  beyond  the  ligature 


Enterostomy  with  McGraw  Elastic  Ligature. 

The  primary  Lembert  suture  in  place.     The  elastic  ligature  has  been  inserted  but  not  tied. 
(From  Dr.  H.  O.  Walker's  original  drawings  of  Dr.  Theodor  McGraw 's  operation.) 

on  each  side.  The  ends  are  cut  two  mm.  beyond  the  silk  ligature.  Then  the 
continuous  silk  suture  is  completed  in  front  of  the  elastic  ligature  so  that  the 
latter  is  completely  buried ;  it  is  important  to  apply  this  suture  accurately  in 
order  to  prevent  any  leakage  when  the  elastic  ligature  begins  to  cut  its  way 
through. 

The   accompanying  illiLstrations   are   taken  directly  from   Dr.  _  McGraw 's 
original  drawings.    They  represent  an  enterostomy,  but  the  principle  is  pre- 


478 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


cisely  the  same  and  it  is  not  difficult  to  imagine  the  operation  changed  to  a 
gastro-enterostomy. 

In  order  to  avoid  error  in  performing  this  operation  it  may  be  well  to 
recapitulate  the  steps: 


Enterostomy  with  McGraw  Elastic  Ligature. 

Showing  posterior  Lembert  suture,  elastic  ligature  in  place  with  first  loop  ready  to  tie. 
(From  Dr.  H.  O.  Walker's  original  drawings  of  Dr.  Theodor  McGraw 's  operation.) 

1.  A  round  rubber  cord  2  mm.  in  diameter,  made  of  the  best  material 
should  be  used. 

2.  A  posterior  row  of  Lembert  sutures  is  applied. 

3.  A  long,  straight  needle  armed  with  the  rubber  ligature  is  passed  into 
the  lumen  of  the  intestine  and  out  again  at  the  desired  distance,  from  5  to  10 
cm.  away  from  the  point  of  introduction. 


SUKGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


479 


4.  "While  an  assistant  holds  the  intestine  the  surgeon  stretches  the  rubber 
in  the  needle  and  ^vhen  quite  thin  draws  it  rapidly  through  the  intestine. 

5.  The  same  step  is  repeated  through  the  stomach. 

6.  A  strong  silk  ligature  is  placed  across  and  underneath  the  rubber  liga- 


EXTEROSTOMT   WITH    McGRAW   ELASTIC   LIGATURE. 

The  primary  Lembert  suture  in  place.  The  elastic  ligature  has  been  tied  but  the  ends 
have  not;  yet  been  cut  short.  The  silk  ligature  securing  the  tied  ends  of  the  elastic  ligature 
has  been  tied  but  the  ends  have  not  been  cut  short. 

(From  Dr.  H.  0.  Walker's  original  drawings  of  Dr.  Theodor  McGraw's   operation.) 


ture  between  the  latter  and  the  point  where  the  stomach  and  intestine  come 
together. 

7.     A  single  tie  is  made  in  the  rubber  ligature  after  the  latter  has  been 
drawn  very  tightly. 


480      SUEGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

8.  The  silk  ligature  is  passed  around  the  euds  of  the  rubber  ligature  where 
they  cross,  and  tied  securely  three  times. 

9.  The  ends  of  the  latter  are  released  and  cut  off,  being  held  by  the  silk 
ligature. 

10.  The  Lembert  suture  is  continued  around  in  front  until  the  point  of  its 
beginning  is  reached,  where  it  will  be  tied. 

11.  Care  must  be  exercised  to  prevent  tying  the  rubber  ligature  too  far 
backward  and  thus  getting  behind  the  posterior  row  of  Lembert  sutures. 

We  are  thus  explicit  in  describing  the  steps  of  this  operation  because  we 
find  that  only  those  who  are  thoroughly  familiar  with  the  method  have  used 
it,  and  apparently  all  with  great  satisfaction. 

CARCINOMA  OF  THE  STOMACH 

Cancer  and  gastric  ulcer.  It  seems  reasonable  to  suppose  that  cancer  of 
the  stomach  is  usually  implanted  upon  the  base  of  a  gastric  ulcer  for  the 
following  reasons : 

1st.  In  all  of  the  recent  or  early  cancers  we  have  encountered  the  growth 
was  located  in  the  edge  of  an  ulcer. 

2nd.  A  careful  study  of  the  history  of  late  cancer,  in  which  the  original 
ulcer  had,  of  course,  been  obliterated  by  the  growth,  it  was  possible  to  elicit 
a  previous  ulcer  history. 

3rd.  In  studying  the  development  of  cancers  in  other  parts  of  the  body 
we  find  that  a  point  is  usually  selected  which  has  been  subjected  to  long  con- 
tinued irritation,  as  in  lip,  face,  rectal  or  uterine  cancer. 

4th.  The  fact  that  there  are  so  few  cancers  of  the  duodenum,  as  compared 
to  the  stomach,  can  be  explained  by  the  fact  that  while  there  is  stasis  in  the 
stomach  there  is  none  in  the  duodenum.  In  other  words,  while  food  contain- 
ing the  cancer  germs  will  remain  in  contact  with  the  ulcer  of  the  stomach 
sufficiently  long  to  obtain  a  foothold,  this  is  not  the  case  in  the  duodenum, 

5th.  It  is  possible  that  these  germs  may  require  an  acid  medium  to  stimu- 
late them  to  attack  the  tissues. 

6th.  It  is  relatively  an  easy  matter  to  overlook  the  history  of  a  previous 
gastric  ulcer,  because  in  the  absence  of  severe  hyperacidity  the  pain  in  these 
cases  is  frequently  not  sufficient  to  be  remembered  through  the  great  distress 
from  which  the  patient  suffers  after  the  cancer  has  developed. 

7th.  In  our  experience  a  large  majority  of  these  patients  have  habitually 
eaten  large  quantities  of  food  which  was  certain  to  be  infected  with  manure, 
such  as  lettuce,  celery,  radishes,  etc.,  so  the  introduction  of  the  cancer  germ 
into  the  open  wound  of  the  ulcer  could  easily  be  explained. 

8th.  These  gastric  ulcers  are  of  such  long  duration  that  the  focus  of  irri- 
tation might  readily  serve  to  locate  cancer  germs  which  might  have  entered 
the  circulation  through  some  other  portal. 

9th.  This  does  not  indicate  that  every  case  of  ulcer  of  the  stomach  will 
ultimately  have  cancer,  any  more  than  that  every  soldier  going  to  battle  will 
be  shot,  but  it  shows  the  wisdom  of  closing  this  opening  for  the  entrance  of 
cancer  by  curing  the  ulcer  early  and  permanently. 

10th.  Much  attention  should  be  given  to  the  early  history  of  these  cases, 
and  to  the  prevention  of  feeding  these  patients  with  unclean,  uncooked  foods. 

Importance  of  early  diagnosis.  The  surgical  treatment  of  cancer  of  the 
stomach  has  received  a  great  deal  of  attention  during  the  past  few  years. 
The  technique  of  resection  of  the  stomach  for  carcinoma  has  reached  the  same 
degree  of  perfection  as  that  connected  with  the  surgical  treatment  of  other 
abdominal  conditions,  and  the  percentage  of  five-year  cures,  especially  in  early 
cases,  compares  very  favorably  with  the  results  in  surgical  treatment  of  cancer 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


481 


in  other  portions  of  the  body,  as  for  instance  cancer  of  the  breast  and  ntems 
The  important  point  in  the  surgical  treatment  of  carcmoma  of  the  stomach  is 
to  be  able  to  make  an  early  diagnosis.    As  soon  as  the  diagnosis  is  made,  or 


Gastro-Enterostomy. 

Eepresents  anterior  gastro-enterostomy  with  the  suture^  ^^  P,;"'^%^°*,^emSen\Vt\'e''^^^^^^ 
in  the  jejunum  and  the  one  at  the  lowest  point  m  the  stomach;    (a)    ^f P^ 'l^^^^^ ^^^^^  "^'^Ih 
position  for  uniting  the  intestine  to  the  stomach;    (b)    represents  the  usual  P^^^    wm^^ 
L  wrong,  giving  rise  to  vomiting,  because  it  forms  a  pouch  into  which  the  contents  ot  tne 
ieiunum  may  empty. 

Taken  from  Dr.  W.  J.  Mayo's  original  drawing. 

it  is  even  strongly  suspected  to  be  a  case  of  carcinoma  of  the  sto^a^^^'/^^^ 
person  becomes  a  surgical  patient  and  should  be  subjected  to  at  least  an 
exploratory  incision. 


482      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

Typical  case.  The  patient  is  a  married  woman,  thirty-five  years  of  age,  giving  the  fol- 
lowing history.  Her  family  history  is  negative.  She  suffered  from  measles  as  a  child, 
menstruated  at  seventeen,  regularly,  but  painful,  before  the  time  of  her  marriage  at  the  age 
of  twenty-eight.  One  year  later  she  had  a  miscarriage,  but  has  otherwise  been  in  good  health. 
Five  months  ago,  patient  began  to  suffer  from  acid  stomach  and  from  the  presence  of  a 
feeling  of  fullness  after  eating,  accompanied  by  eructations  of  gas.  She  has  also  suffered 
severely  from  constipation.  For  the  past  two  months  she  has  vomited,  usually  after  taking 
solid  food,  occasionally,  however,  she  would  retain  any  kind  of  food  in  her  stomach  for  two 
or  three  days  and  then  vomit  all  that  she  had  taken  during  this  period  of  time.  She  has  not 
suffered  any  pain  and  her  temperature  has  been  normal.  She  has  occasionally  been  slightly 
jaundiced.     The  jiatient  has  never  been  very  well  nourished. 

Present  condition.  The  patient  is  quite  emaciated,  being  fifteen  pounds  below  her  usual 
weight;  her  tongue  is  coated  and  she  is  very  hungry;  her  bowels  are  constipated.  Cathartics 
give  rise  to  nausea.  Temperature  is  98°  F.,  the  pulse  86,  regular  and  fairly  strong.  Heart, 
lungs  and  kidneys  are  normal.  The  abdomen  is  distended,  but  not  tender  upon  pressure. 
There  is  no  free  fluid  in  the  peritoneal  cavity.  The  stomach  is  prolapsed  and  distended,  the 
lower  border  extends  two  inches  below  the  umbilicus.  Succussion  sounds  are  marked  upon 
shaking  the  abdomen.  A  hard,  elliptical  body,  movable  with  respiration,  can  be  felt  in  the 
right  hypochondriac  region.  There  is  a  tympanitic  space  between  this  mass  and  the  costal 
arch.     The  mass  is  movable  in  every  direction. 

Diagnosis.  This  history  would  indicate  beyond  a  doubt  that  there  exists 
in  this  case  an  obstruction  of  the  pyloric  end  of  the  stomach.  This  may  be  due 
to  the  presence  of  a  malignant  growth  corresponding  to  the  tumor,  which  can 
easily  be  demonstrated,  or  it  may  be  due  to  a  non-malignant  stricture  of  the 
pylorus,  or  to  a  short  bend  in  this  part  of  the  alimentary  canal.  The  tumor 
is  farther  to  the  right  than  we  usually  find  a  carcinoma  of  the  pylorus  and 
it  might  readily  be  a  distended  gall-bladder  or  even  a  tumor  of  this  organ,  or 
it  might  be  a  movable  kidney  containing  a  small  tumor.  The  youth  of  the 
patient  might  be  considered  an  argument  against  the  diagnosis  of  carcinoma 
of  the  pylorus. 

Notwithstanding  these  facts,  there  can  scarcely  be  a  doubt  but  that  this 
patient  is  suffering  from  the  presence  of  a  carcinoma  obstructing  the  pylorus, 
because  the  history  and  the  findings  upon  physical  examination — hyperacidity, 
pain,  hemorrhage,  dilatation,  emaciation,  and  tumor — are  very  characteristic. 

Indications  for  operation.  Judging  from  the  size  of  the  tumor  and  the 
amount  of  obstruction  present,  it  is  not  at  all  likely  that  an  operation  will 
result  in  the  removal  of  the  malignant  growth,  or  in  case  a  removal  is  accom- 
plished it  is  not  at  all  probable  that  this  will  result  in  a  radical  cure.  Conse- 
quently the  best  that  can  be  expected  from  an  operation  is  simply  a  certain 
degree  of  temporary  relief.  This  relief  will  consist  in  the  establishment  of  a 
free  communication  between  the  stomach  and  the  small  intestine.  As  a  result 
of  this  the  nausea,  vomiting  and  pain  will  rapidly  disappear,  the  nutrition 
will  improve  and  the  patient  will  no  longer  absorb  decomposition  products 
from  the  stomach.  Her  cachexia  will  consequently  disappear,  she  will  gain  in 
weight  and  strength  and  will  imagine  herself  quite  well  for  a  time. 

Sooner  or  later  the  carcinoma  will  have  involved  so  great  a  portion  of  the 
stomach  and  the  surrounding  organs  that  she  will  succumb  to  the  disease,  but 
it  may  be  a  considerable  time  before  this  is  to  be  expected. 

Preparatory  treatment.  Gastric  lavage  will  be  performed  night  and  morn- 
ing for  one  or  two  days  until  the  stomach  contents  no  longer  have  an  offensive 
odor.  The  morning  of  the  day  before  the  operation  two  ounces  of  castor  oil 
will  be  introduced  through  the  stomach  tube,  after  the  gastric  lavage  has 
been  completed.  In  the  meantime  some  aseptic  predigested  food  will  be  given 
every  three  hours. 

Should  the  oil  not  produce  a  very  free  evacuation  of  the  bowels,  the  same 
dose  will  be  given  in  the  same  manner  every  twelve  hours  until  the  desired 
effect  has  been  accomplished.  If  the  oil  is  not  retained  in  the  stomach  free 
evacuation  of  the  bowels  will  be  accomplished  if  possible  by  means  of  enemata. 


I 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


483 


On  the  morning  before  the  operation  the  stomach  will  again  be  thoroughly 
cleansed  by  means  of  gastric  lavage. 

Technique.     The  incision  is  made  as  in  the  previous  case.     We  find  as  we 
had  expected,  an  extensive  involvement  of  the  entire  pylorus  with  the  tumor 


J 


Gastro-Enterostomy. 

Eepresents  anterior  gastro-enterostomy  with  the  omentum  folded  over  the  point  of  union 
between  the  stomach  and  tlie  jejunum  to  increase  the  safety  of  the  operation. 
Taken  from  Dr.  W.  J.  Mayo's  original  drawing. 


extending  well  up  on  the  lesser  curvature.  The  lymph  glands  to  a  considerable 
distance,  especially  behind  the  pylorus  and  along  the  lesser  and  greater  curva- 
ture of  the  stomach,  are  involved.  It  seems  plain  that  the:  complete  removal 
of  these  glands,  together  with  the  tumor,  is  not  possible,  and  a  partial  removal 
would  only  serve  to  excite  a  more  rapid  growth,  consequently  no  benefit  could 


484      SUEGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

come  from  an  attempt  at  a  radical  operation  and  it  would  not  be  wise  to  make 
the  effort. 

The  healthy  portion  of  the  stomach  is  greatly  dilated  on  account  of  the 
almost  complete  closure  of  the  pyloric  opening.  The  greater  curvature  ex- 
tends more  than  two  inches  below  the  umbilicus.  The  operation  from  which 
the  greatest  amount  of  benefit  will  be  derived  is  a  simple  gastro-enterostomy. 

In  planning  a  gastro-enterostomy  for  drainage  in  carcinoma  of  the  stomach, 
the  opening  should  be  chosen  at  a  point  quite  distant  from  the  carcinoma. 
In  the  majority  of  cases  an  anterior  gastro-enterostomy  answers  this  purpose 
better  than  a  posterior.  In  the  past  the  authors  frequently  used  the  Murphy 
button  for  making  the  anastomosis. 

The  jejunum  is  now  brought  up  out  of  the  abdominal  wound  and  a  point 
selected  twelve  to  sixteen  inches  from  the  mesentery  of  the  transverse  colon. 
A  small,  longitudinal  incision  is  made  through  the  peritoneum  and  muscular 
coat  down  to  the  mucous  coat,  then  a  purse-string  stitch  is  applied.  Then  the 
mucous  membrane  is  cut  and  the  larger  segment  of  a  Murphy  button  is 
inserted  and  the  purse-string  suture  carefully  tied.  It  is  important  to  apply 
the  purse-string  suture  close  to  the  edge  of  the  wound  in  the  intestine  in  order 
to  prevent  the  tissues  being  drawn  together  in  irregular  masses  around  the 
button. 

By  drawing  a  small  bunch  of  moist  cotton  through  the  hole  in  the  button 
sufficiently  firm  to  prevent  leakage  much  annoyance  may  be  avoided,  because 
this  pledget  of  cotton  can  be  easily  removed  before  uniting  the  two  lobes  of 
the  button.  This  intestine  with  the  button  in  place  is  now  surrounded  with  a 
piece  of  moist  gauze  and  placed  to  one  side  while  the  other  half  of  the  button 
is  inserted  into  the  stomach  in  very  much  the  same  way. 

We  have  selected  the  most  dependent  portion  of  the  greater  curvature 
of  the  stomach,  but  here  we  find  the  large  artery,  the  gastro-epiploic,  with  its 
large  branches  extending  at  right  angles  with  the  greater  curvature  of  the 
stomach.  AVe  will  select  a  point  half  way  between  two  of  these  branches  and 
make  our  incision  through  the  peritoneal  and  muscular  coats  down  to  the 
mucous  coat.  The  muscular  coat  will  retract  somewhat,  and  here  again  we 
exercise  the  same  care  in  inserting  the  purse-string  suture  near  the  edge  of 
the  wound,  in  order  not  to  draw  too  much  tissue  between  the  rims  of  the 
button.  The  smaller  segment  of  the  button  is  now  inserted  and  the  purse- 
string  suture  tied.  It  has  been  so  applied  as  to  avoid  having  the  knots  in  the 
two  sutures  meet  when  the  button  has  been  closed.  After  withdrawing  the 
pledget  of  cotton  from  the  opening,  the  two  segments  of  the  button  are  ad- 
justed to  each  other  and  pressed  tosrether  with  a  moderate  amount  of  force, 
care  being  taken  to  push  in  any  small  portion  of  serous  surface  which  might 
not  have  adjusted  itself  spontaneously. 

A  stomach  tube  should  now  be  inserted  and  the  stomach  should  be  carefully 
irrigated  with  water  at  a  temperature  of  105°  F.,  to  wash  away  any  mucus  or 
blood  which  may  have  been  collected,  and  to  demonstrate  the  fact  that  the 
union  between  the  stomach  and  jejunum  is  perfect. 

In  doing  the  anterior  gastro-enterostomy  it  is  wise  to  add  Ilartmann's 
suggestion  of  stitching  the  intestine  to  the  stomach  wall  an  inch  above  the 
proximal  side  with  a  mattress  suture.  A  second  suture  is  placed  in  same 
manner  about  one  inch  on  the  distal  side  of  the  anastomosis.  This  prevents 
the  jejunum  from  kinking  on  the  gastro-jejunal  opening. 

it  is  again  important  to  select  the  lowest  point  in  the  stomach,  in  order  to 
secure  perfect  drainage  of  this  organ,  and  especially  for  the  purpose  of  pre- 
venting the  flow  of  bile  from  the  duodenum  into  the  stomach.  It  is  also 
important  to  remain  as  great  a  distance  from  the  diseased  portion  of  the  organ 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


485 


as  is  compatible  with  securing  the  most  dependent  portion;  fortunately,  the 
latter  usually  lies  very  well  to  the  left. 

In  patients  who  are  greatly  reduced  in  strength  it  is  well  to  reinforce  the 


Gastro-Exterostomt. 

Anterior   gastro-enterostomy.      The   jejunum   being  united  to   the   stomach   at  its   lowest 
point,  which  will  prevent  the  regurgitation  of  bile,  ' '  vicious  circle. ' ' 
Taken  from  Dr.  W.  J.  Mayo 's  original  drawing. 


Murphy  button  to  a  certain  extent  by  the  use  of  a  cuff  formed  out  of  the 
omentum,  as  shown  in  the  plate. 

It  has  occasionally  happened  after  a  gastro-enterostomy  in  greatly  reduced 
patients,  that  a  sudden  motion,  such  as  would  be  experienced  during  a  severe 
paroxysm,  of  coughing,  sneezing  or  vomiting,  would  be  followed  by  a  loosening 
of  the  anterior  portion  of  the  union  between  the  stomach  and  the  intestine. 


486  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

In  these  cases  it  is  wise  to  enforce  this  union  by  employing  the  omentum,  which 
is  always  well  nourished  and  abundantly  supplied  with  blood  vessels,  and  will 
consequent!}'  make  up  for  the  deficiencies  in  the  nutrition  of  the  stomach  wall. 

Non-operative  cases.  In  case  an  operation  is  refused  by  a  patient  in  this 
condition,  we  try  to  secure  a  degree  of  comfort  by  the  use  of  opium.  AVe  also 
teach  him  to  perform  gastric  lavage  whenever  he  is  nauseated.  In  many  of 
these  patients  one  can  secure  a  great  degree  of  comfort  by  pursuing  the  fol- 
lowing plan :  Gastric  lavage  is  performed  in  the  morning  directly  before 
taking  breakfast,  which  should  consist  as  much  as  possible  of  food  that  can  be 
absorbed  from  the  stomach,  therefore  liquid,  in  order  not  to  clog  whatever 
slight  opening  may  still  exist  in  the  pylorus.  Two  hours  later  the  remnants 
of  this  food  are  again  removed  by  gastric  lavage.  The  same  plan  is  followed 
at  noon  and  at  night.  In  this  manner  the  food  is  not  mixed  with  decomposing 
mucus  and  remains  from  a  previous  meal,  which  are  partly  decomposed  and 
partly  digested. 

After  a  short  period  of  practice  these  patients  frequently  enjoy  this  plan, 
and  many  of  them  improve  greatly  in  appearance,  because  they  no  longer 
have  to  absorb  these  products  of  decomposition.  It  is  not  infrequent  for 
patients  to  gain  in  weight  under  this  form  of  treatment,  and  there  is  usually 
a  great  reduction  in  pain  in  cases  in  which  this  symptom  is  marked. 

A  fear  of  producing  hemorrhage  by  the  use  of  gastric  lavage  has  been 
expressed,  but  we  believe  that  this  danger  is  greatly  over-estimated.  Before 
we  became  familiar  Avith  the  use  of  the  ^lurphy  button,  we  had  occasion  to 
treat  many  cases  in  the  manner  just  described,  and  never  found  any  difficulty 
from  hemorrhage. 

RESECTION  OF  THE  PYLORUS 

Had  we  encountered  a  removable  tumor  of  the  pylorus  in  the  case  above 
outlined,  our  treatment  would  not  have  varied  as  regards  the  communication 
between  the  stomach  and  the  intestine,  but  this  would  have  been  preceded 
by  the  excision  of  the  pylorus  by  a  method  which  will  be  described  presently. 

There  are  several  valid  reasons  for  preferring  a  gastro-enterostomy,  such 
as  has  been  described,  to  a  direct  end-to-end  union  between  the  stomach  and 
the  duodenum  after  the  excision  of  the  pylorus:  1.  It  is  much  more  easily 
accomplished ;  2.  The  operation  requires  much  less  time,  which  is  an  important 
feature  in  many  of  these  cases;  3.  Surfaces  completely  covered  with  peri- 
toneum can  be  united;  4.  There  is  no  tension;  5.  The  adjustment  can  be  made 
more  accurately,  because  in  the  end-to-end  approximation  of  the  duodenum  to 
the  stomach  there  is  a  great  difference  in  the  lumen  which  varies  with  the 
amount  of  tissue  that  has  to  be  removed  from  the  stomach ;  6.  The  attachment 
being  at  the  most  dependent  portion  of  the  stomach,  the  drainage  is  more 
likely  to  be  satisfactory. 

With  the  hearty  consent  of  "\V.  J.  Mayo  the  following  extract  is  used.  His 
work  in  this  field  is  classical  and  authoritative.  The  accompanying  illustra- 
tions are  also  taken  from  his  original  drawings. 

Radical  operations  for  the  cure  of  cancer  of  the  pyloric  end  of  the  stomach. 
[Seventy  per  cent,  of  all  gastric  carcinomata  involve  the  pyloric  portion, 
and  sixty  per  cent,  have  their  origin  at  the  pylorus  or  within  three  inches  of 
it.  Considering  the  fact  that  radical  operation  was.  successfully  performed 
in  the  time  of  Billroth  (1881),  before  tlie  inception  of  modern  abdominal 
surgery,  and  that  during  the  succeeding  years  more  or  less  work  has  been 
done  in  this  field,  it  is  curious  that  pylorectomy  and  partial  gastrectomy  have 
not  as  yet  achieved  an  accepted  surgical  position.  There  have  been  a  number 
of  reasons  for  this  anomaly;  first,   a  belief  that  the  diagnosis  could  not  be 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      487 

made  before  the  case  had  advanced  bej'ond  the  possibility  of  cure,  and,  second, 
that  the  operation  was  difficult,  prolonged  and  bloody,  with  an  almost  pro- 
hibitive mortality.  The  first  proposition  is  to  a  considerable  extent  true;  but 
not  entirely  so,  as  we  have  in  exploratory  incision  the  one  diagnostic  resource 
which  is  reliable  and  which  must  be  resorted  to  in  the  large  majority  of  cases 
before  a  surgical  diagnosis  can  be  made.  AVithout  it  the  truth  is  but  slowly 
established  together  with  progressive  hopeless  involvement.  Exploration  can 
be  safely  accomplished  through  a  small  incision  and  with  a  short  time  of  dis- 
ability. It  is  said  that  the  patient  will  not  submit  to  an  abdominal  incision 
upon  suspicion.  Herein  we  do  the  intelligence  of  the  public  an  injustice ;  we 
have  seldom  been  refused  the  opportunity,  when  the  matter  has  been  fairly 
and  candidly  laid  before  the  patient  and  his  friends.  The  plea  for  delay  has 
more  often  come  from  the  attending  physician. 

Without  going  into  the  question  as  to  the  symptoms  which  would  con- 
stitute a  basis  for  exploration,  the  writer  would  express  the  opinion  that  the 
early  diagnosis  must  be  based  upon  clinical  phenomena,  the  result  of  observa- 
tion and  experience. 

Some  misleading  statements.  In  attempting  to  solve  some  of  these  prob- 
lems we  have  encountered  a  number  of  misleading  statements,  which  seem  to 
have  been  generally  accepted.  Of  these,  three  are  of  sufficient  importance  to 
deserve  brief  discussion:  (a)  The  value  of  laboratory  methods  of  diagnosis; 
(b)  the  significance  of  a  palpable  tumor;  (c)  the  history  of  previous  ulcer. 

(a)  Laboratory  methods  of  diagnosis  are  chiefly  based  upon  the  chemistry 
of  the  gastric  secretions  (test  meals  and  so  forth)  and  the  microscopical 
examination  and  chemical  reactions  of  gastric  "findings,"  as  well  as  the  urine, 
feces  and  blood.  In  the  surgical  stage  these  examinations  have  little  value, 
but  gain  in  diagnostic  importance  with  the  progress  of  the  disease,  to  become 
of  the  greatest  value  only  when  the  patient  is  in  a  hopeless  condition.  My 
colleagues,  Drs.  Graham  and  Millet,  in  the  examination  of  somewhat  over 
1,500  stomach  and  duodenal  cases,  of  which  430  came  to  operative  demonstra- 
tion, showed  this  beyond  question.  These  examinations  should  be  made,  but 
exploration  should  not  be  delayed  by  reason  of  the  inconclusive  nature  of  the 
results. 

(b)  Tionor.— The  dictum  was  advanced  many  years  ago  that  the  presence 
of  a  tumor  of  itself  demonstrated  inoperability.  This  is  by  no  means  true ;  a 
small  movable  tumor  in  the  pyloric  region  may  be  a  favorable  indication. 
The  early  diagnosis  of  cancer  depends  in  a  great  measure  upon  the  introduc- 
tion of  mechanical  phenomena  from  obstruction  at  the  pylorus,  late  vomiting, 
dilatation,  pain,  gas,  etc.,  with  or  without  palpable  tumor,  and  it  is  the  inter- 
ference with  gastric  motility — the  progress  of  food  from  the  stomach — which 
early  calls  the  attention  of  the  patient  to  his  trouble,  and  not  the  presence  of 
the  cancer  itself.  AVithout  these  symptoms  a  surgical  diagnosis  would  seldom 
be  made.  In  our  experience  the  patient  with  marked  symptoms  of  cancer  of 
the  stomach,  but  without  any  evidence  of  pyloric  obstruction,  proves  on  ex- 
ploration to  be  the  victim  of  advanced  and  hopeless  disease  of  the  body,  in 
which  there  were  no  symptoms  during  the  operable  period. 

(c)  A  history  of  previous  ulcer  with  complete  recovery  during  a  prolonged 
period  of  time  is  apt  to  be  taken  as  an  indication  that  a  present  gastric  trouble 
is  due  to  a  recurrence  of  the  ulcer  and  lead  the  patient  and  attendant  physician 
to  postpone  interference.  Usually  this  is  true,  but  too  often  the  renewal  of 
symptoms  is  due  to  cancer  development  upon  an  ulcer  base.  TVe  have  had 
this  occur  a  number  of  times.  The  author  has  become  a  convert  to  the  belief 
that  cancer  frequently  develops  upon  an  old  ulcer  scar.  Graham,  in  145  cases 
of  cancer  of  the  stomach  which  came  to  operation  at  our  hands,  found  a  pre- 
vious history  of  ulcer  in  sixty  per  cent,  of  the  cases,  although  years  may  have 


488 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


elapsed  after  healing  of  the  ulcer  before  the  cancer  began.  Lehert  says  that 
nine  per  cent,  of  ulcers  develop  cancer — that  is,  pass  directly  from  the  one 
condition  to  the  other.  Ochsner,  Fiitterer,  Dunn  and  others  believe  that  the 
irritation  of  healed  ulcer  defects  in  the  mucosa  furnish  the  starting  point  for 
the  majority  of  cancers.  JNIurphy  rightly  says  that  precancerous  lesions  can 
usually  be  demonstrated  in  the  history  of  the  case.  It  is  to  be  noted  that  the 
topography  of  cancer  and  ulcer  is  nearly  identical. 


i^ 


0  '■ 


\      W  ^^ 

■    ^astroenter-  J^    x 
illelJo  large 
of  stomach 


J   ^    .^'.the  proximal 
-\\Jejvnum  fastenea 
.^,,     \  upwards  on  Tuba 
~\\     of  stomach 

tube  of  stomach  Joined 
vv'ith jejunum  bij  end  to 
5id&    anastomosis 


Beck  's  Gastro-Exterostomy. 

A  communicating  tube  has  been  constructed,  taking  a  flap  from  the  cardiac  end  of  the 
greater  curvature  of  the  stomach  and  uniting  the  defect  produced  by  this,  constructing  the 
tube  and  implanting  it  laterally  into  the  jejunum  either  behind  or  in  front  of  the  transverse 
colon. 

The  above  figures  show  the  manner  in  which  the  flap  is  constructed.  The  cavity  of  the 
dome  of  the  stomach  and  the  duodenum  are  closed  with  two  long  jawed  clamps  which  also 
compre.<s  the  blood-vessels  and  prevent  hemorrhage. 


The  determination  of  operative  intervention.  The  second  proposition  con- 
cerns the  operation  itself.  There  are  two  local  manifestations  of  the  malignant 
process  upon  which  the  advisability  of  operation  depends:  (a)  Local  extent 
of  disease;  (b)  lymphatic  involvement. 

(a)  Movahility  of  the  growth  is  a  very  important  factor  in  judging  of  the 
extent  of  disease.  Limitation  to  the  pyloric  end  of  the  stomach  is  also  of 
prime  importance.  Extension  to  neighboring  organs  usually  contraindicates 
operation,  with  the  occasional  exception  of  the  transverse  mesocolon.  The 
duodenum  is  rarely  involved  to  any  considerable  extent.  Adhesions  are  a 
serious  complication,  not  only  because  they  are  the  advance  guard  of  the 
cancerous  process,  but  in  that  they  add  to  the  difficulties  and  dangers  of  the 
operation.    Haberkant  found  a  death  rate  of  seventy-three  per  cent,  operated 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH      489 

upon  in  the  face  of  extensive  adhesions,  and  twenty-seven  per  cent,  "without 
such  complication.  Mikulicz  had  a  mortality  of  seventy  per  cent,  when  there 
was  close  adhesion  to  the  pancreas.  A  moderate  amount  of  adhesions  which 
permit  of  free  motility  of  the  growth  have  not  materially  infuenced  the  prog- 
nosis in  our  experience. 

(h)  Lymphatic  infection.  This  is  the  most  important  element  in  the  at- 
tempt at  cure  of  cancer  of  the  stomach,  because  the  most  difficult  to  estimate 
in  its  extent.  The  mere  presence  of  enlarged  lymph  nodes  does  not  necessarily 
imply  cancer.  Glandular  hyperplasia  occurs  with  great  frequency  in  ulcer 
as  the  result  of  infection,  and  the  location  of  such  lymph  nodes  may  lead  to 
the  site  of  ulceration,  as  pointed  out  by  Lund.  Ulcerating  gastric  carcinomata 
may  give  rise  to  infected  glands  without  epithelial  invasion,  but  in  practically 
all  cases  of  gastric  cancer  the  lymphatic  structures  are  involved.  In  the  iJres- 
lau  clinic  twenty  cases  out  of  twenty-one  showed  glandular  involvement.  In 
a  general  way  the  lymph  channels  follow  the  blood  vessels.  On  the  lesser 
curvature  the  blood  and  lymph  vessels  lie  in  the  wall  of  the  stomach  itself, 
and,  as  pointed  out  by  Mikulicz,  it  is  necessary  in  every  case  of  pyloric  cancer 
to  remove  all  of  the  lesser  curvature  to  the  gastric  artery.  For  convenience 
this  situation  on  the  lesser  curvature  for  beginning  of  the  line  of  excision  may 
be  called  the  Mikulicz  point  of  election. 

To  Cuneo  we  ow^e  a  debt  of  gratitude  for  his  masterly  exposition  of  the 
lymph  drainage  of  the  stomach.  He  showed  that  there  are  but  few  lymph 
glands  along  the  greater  curvature,  and  these  are  confined  to  the  pyloric 
region.  (See  plate. j  These  glands,  with  the  blood  vessels,  lie  at  some  distance 
from  the  greater  curvature,  thus  enabling  rapid  expansion  and  contraction  of 
the  stomach  without  interference  with  the  circulation.  The  lymph  stream  in 
this  situation  flows  from  left  to  right  and  does  not  drain  more  than  one-third 
of  the  adjacent  stomach,  two-thirds  going  into  the  lymph  channels  of  the  lesser 
curvature.  In  the  immediate  vicinity  of  the  pylorus,  however,  it  drains  its 
fair  share. 

The  lymphatics  of  the  greater  and  lesser  curvatures  enter  the  deep  receiv- 
ing glands  about  the  cceliac  axis  on  the  anterior  surface  of  the  aorta.  Cuneo 
practically  demonstrated  that  the  fundus  and  two-thirds  of  the  greater  curva- 
ture are  free  from  lymphatic  involvement  in  cancer  of  the  pylorus.  Hartmann 
at  once  seized  upon  this  basic  principle  and  fixed  the  point  of  election  for  the 
line  of  section  upon  the  greater  curvature  at  a  healthy  place  on  the  gastric 
wall,  to  the  left  of  these  glands.  The  distance  to  the  left  is  regulated  by  the 
extent  of  the  disease. 

In  a  previous  communication  the  author  called  attention  to  the  lymphatic 
isolation  of  the  dome  of  the  stomach.  This  has  also  been  noted  by  Robson 
and  Moynihan.  It  is  evident  that  the  extent  of  this  free  zone  along  the  greater 
curvature  is  much  wider  in  pyloric  cancer  than  was  at  that  time  considered 
possible.  The  retention  of  this  portion  of  the  stomach  relieves  the  operation 
of  many  serious  difficulties  without  loss  of  completeness. 

Operative  detail.  The  operation  itself  can  be  divided  into  (a.)  incision  and 
exposure;  (bj  control  of  hemorrlmge;  (e)  closure  of  the  stomach  and  duodenal 
stamps;  (d)  re-establisliment  of  the  g astro-intestinal  canal;  (e)  avoidance  of 
infection;  (i)  measures  for  preventing  shod:. 

The  patient's  stomach  should  be  cleansed  the  day  before,  rather  than  imme- 
diately previous  to  operation,  as  it  may  prove  to  be  somewhat  trying  to  one 
unaccustomed  to  the  process.  A  small  amount  of  liquid  nourishment  may  be 
given  after  the  lavage,  but  nothing  on  the  morning  of  the  operation.  The 
teeth  and  mouth  should  have  been  previously  cleansed  as  well  as  possible. 
A  preliminary  hj^podermatic  injection  of  morphine,  to  enable  the  anesthetic 
to  be  reduced  to  a  minimum,  may  be  of  value. 


490 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


(A)  A  small  incision  is  made  in  the  median  line,  half  way  between  the 
ensif orm  cartilage  and  the  nmbilicus ;  through  this  two  fingers  are  introduced 
for  exploration.  If  the  condition  is  inoperable,  the  incision  is  closed  and  a 
sufficient  number  of  buried,  non-absorbable  mattress  sutures  of  silk,  linen  or 


Stomach  Showing  Distribution  op  Lymph  Nodes. 

As  demonstrated  by  Hartmann  and  Cuneo. 
(From  original  drawings  of  Dr.  W.  J.  Mayo.) 

wire  introduced  into  the  aponeurotic  structure  of  the  linea  alba  to  enable  the 
patient  to  get  about  at  once  and  to  return  to  his  home  and  friends  within  a 
few  days.  If  sutured  in  the  usual  manner  and  the  patient  placed  in  bed  for 
two  or  three  weeks,  many  of  them  will  develop  hypostatic  pulmonary  lesions, 
loss  of  appetite,  swelling  of  the  feet  and  so  forth,  and  may  be  unable  to  spend 


SUEGERY  OF  THE  ESOPHAGUS  AND  STOMACH  491 

their  few  remaining  days  at  home.     "When  an  advanced  cancer  case  goes  to 
bed  for  a  week  or  two  the  chances  of  his  getting  about  again  are  small. 

Non-absorbable  sutures,  buried  in  fixed  structures  such  as  fascia  and  bone, 
seldom  give  trouble  and  furnish  immediate  strength.  In  muscle  and  movable 
tissues  atrophy  necrosis  may  occur.  We  limit  their  use,  however,  to  the  hope- 
less cases  of  exploration  for  malignant  disease.  If  operation  is  decided  upon, 
the  small  exploring  incision  is  rapidly  enlarged  to  four  or  five  inches  and  a 
sufficiency  of  the  gastro-hepatic  omentum  is  tied  off;  at  once  close  to  the  liver. 
This  opens  the  lesser  cavity  of  the  peritoneum  and  mobilizes  the  pyloric  end 
of  the  stomach  with  tumor.  The  entire  area  is  now  packed  otf  with  gauze 
pads. 

(B)  Control  of  hemorrhage.  The  pyloric  end  of  the  stomach  is  supplied 
by  four  blood  vessels,  the  gastric  and  superior  pyloric  above,  and  the  right 
and  left  gastro-epiploics  below.  By  ligating  these  four  vessels  early  the  opera- 
tion is  rendered  practically  bloodless.  The  gastric  is  doubly  tied  about  one 
inch  below  the  cardiac  orifice  at  a  point  where  it  joins  the  lesser  curvature, 
and  divided  between  the  ligatures.  The  superior  pyloric  is  doubly  tied  and 
divided.  The  fingers  are  passed  beneath  the  pylorus,  raising  the  gastro-colic 
omentum  from  the  transverse  meso-colon,  and  in  this  way  safe  ligation  behind 
the  pylorus  of  the  right  gastro-epiploic  artery,  or  in  most  cases  its  parent 
vessel,  the  gastro-duodenal,  is  secured.  The  left  gastro-epiploic  is  now  tied 
at  an  appropriate  point  and  the  necessary  amount  of  gastro-colic  omentum 
doubly  tied  and  cut.  Sometimes  the  right  margin  of  the  omentum  becomes 
very  much  congesteH  from  the  venous  obstruction  produced  in  this  way.  In  a 
few  cases  it  has  seemed  wise  to  excise  the  devitalized  omentum,  especially  if 
drainage  is  to  be  used,  with  its  attendant  possibilities  of  secondary  infection. 
In  one  such  case  a  considerable  amount  of  omentum  tissue  sloughed,  although 
fortunately  the  patient  recovered.  If  drainage  is  not  used  it  will  act  as  an 
omental  graft  and  give  no  trouble.  It  is  important  that  in  ligating  the  gastro- 
duodenal  vessel  and  the  gastro-colic  omentum  the  fingers  should  raise  the 
structures  away  from  the  middle  colic  artery  which  runs  immediately  beneath 
in  the  transverse  meso-colon. 

The  lesser  cavity  of  the  peritoneum  is  a  potential  rather  than  an  actual 
space,  as  the  two  layers  of  peritoneum  are  in  contact,  and  the  middle  colic  has 
been  accidentally  caught  in  tying  the  vessels  from  without  inward.  As  this 
vessel  usually  is  the  entire  supply  of  the  transverse  colon  ligation  may  result 
in  gangrene  of  the  transverse  colon,  as  pointed  out  by  Kronlein.  This  has 
happened  a  number  of  times. 

The  control  of  hemorrhage  is  very  similar  to  the  ligation  of  the  four  vessels 
concerned  in  abdominal  hysterectomy  and  fully  as  easy. 

(C)  The  duodenum  is  doubl3^  clamped  and  divided  between  with  the 
actual  cautery  to  prevent  inoculation  of  the  cut  surfaces  with  cancer.  The 
stump  should  be  left  one-fourth  inch  long,  and  before  removing  the  clamp  a 
running  suture  of  catgut  is  introduced  through  the  seared  stump  and  tied  as 
the  clamp  is  removed.  A  purse-string  suture  of  silk  or  linen  three-quarters 
of  an  inch  below  the  stump,  enables  inversion  in  a  similar  manner  to  the  stump 
of  the  appendix.  A  long  Kocher  clamp  is  now  placed  from  the  tied  gastric 
artery  at  Mikulicz's  point  of  election,  in  an  oblique  direction,  so  as  to  save  as 
much  as  possible  of  the  greater  curvature  to  Hartmann's  point  of  election  on 
the  greater  curvature.  The  blades  of  this  clamp  should  be  covered  with  rubber 
tubing  and  the  compression  should  be  just  sufficient  to  retain  the  tissues  in  its 
grasp.  A  second  clamp  is  applied  on  the  tumor  side  to  prevent  leakage.  The 
tissues  between  are  severed  with  the  Pacquelin  cautery,  one-quarter  of  an 
inch  from  the  holding  clamp,  and  as  the  tissues  are  divided  several  catch  for- 
ceps are  applied  to  the  projecting  stump  to  prevent  retraction  of  some  pari 


492 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


of  the  gastric  -".vall  from  the  grasp  of  the  Kocher  clamp.  The  pyloric  end  of 
the  stomach,  with  the  tumor  guarded  against  leakage  by  the  clamp  at  each 
end,  is  removed.  The  cauterized  stump  projecting  beyond  the  Kocher  clamp 
is  rapidh'  sutured  with  a  catgut  button-hole  suture,  from  the  greater  to  the 


>l>j:.l\^n     Wi'iH    <_..:.>      .    w,..,     ,jy     i'VLOKI>. 

Showirg  lines  chosen  in  making  pyloreetomy  or  partial  gastrectomy  by  various  surgeons. 
(From  original  drawings  of  Dr.  "W.  J.  Mayo.) 


lesser  curvature,  through  all  the  coats  of  the  stomach,  and  in  the  same  manner 
directly  back,  and  tied  at  the  starting  jioint ;  this  prevents  hemorrhage  as  well 
as  leakage.  The  doubling  of  this  form  of  suture  holds  the  approximated  edges 
evenl}'  in  line.  The  Kocher  clamp  is  now  removed  and  any  bleeding  point 
caught  and  tied. 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


493 


The  final  suture,  of  silk  or  linen,  is  now  introduced  and  made  after  the  right- 
angled  plan  of  Gushing.  It  is  taken  sufficiently  far  from  the  catgut  suture  line 
to  enable  easy  approximation  of  the  sero-muscular  layers  without  tension. 

Steps  (d)   and  (c)  can  be  varied  sometimes  to  advantage.     AVe  have  fre- 


WllllA.T,  IIVU/O. 


Stomach  with  Caecixoma  of  Ptloetjs. 

ShoTN-ing  manner  of  applying  forceps  to  duodenum  and  also  ligation  of  lesser  omentum. 
Also  showing  lymph  nodes  usually  involved  and  line  of  excision  in  early  eases. 
(From  original  drawing  of  Dr.  W.  J.  Mayo.j 

quently  tied  off  the  gastro-hepatic  ligament  and  the  superior  vessels  and  at 
once  double  clamped  and  divided  the  duodenum.  By  pulling  upward  on  the 
stomach  side  the  gastro-duodenal  artery  is  easily  caught,  tied  and  divided, 
and  the  operation  proceeded  with  as  before.  In  a  few  cases  we  have  begun  on 
the  stomach  side,  ligating  and  dividing  the  gastric  and  left  gastro-epiploie  ves- 
sels first,  then  clamping,  dividing  and  suturing  the  stomach  as  before,  complet- 


494      SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

ing  the  duodenal  end  with  its  vessels  last.  This  is  favored  by  Hartmann.  If 
there  are  adhesions,  however,  the  first  plan  mobilizes  the  stomach  much  better 
and  enables  more  accurate  work  and  greater  exposure  of  that  part  of  the 
stomach,  which,  at  the  line  of  section,  lies  naturally  deep  under  the  costal  arch. 

(D)  Restoration  of  the  gastro-intestinal  canal  was  first  accomplished  by 
Billroth,  by  joining  directly  the  cut  surface  of  the  duodenum  to  the  shortened 
stomach,  the  opening  of  the  latter  viscus  being  partly  sutured  to  reduce  it 
to  the  size  of  the  duodenal  end.  The  angle  where  the  three  suture  lines  come 
together  leaked  so  often,  especially  if  there  was  the  least  tension,  that  it  was 
called  the  ' '  fatal  suture  angle. ' '  Kocher  saw  the  defect  in  this  method  and 
began  implanting  the  cut  end  of  the  duodenum  to  the  posterior  gastric  wall 
at  a  sound  point,  and  completely  closed  the  stomach.  This  method  gives 
excellent  results,  if  there  be  no  tension  in  bringing  the  parts  into  easy  apposi- 
tion.   Unfortunately  this  often  happens. 

Billroth 's  second  operation  is  the  operation  of  choice: — Complete  clos- 
ure of  the  duodenal  and  stomach  ends  with  an  independent  gastro-jejunos- 
tomy  of  the  usual  type.  It  has  the  two  chief  requisites  of  gastro-intestinal 
anastomosis ;  there  is  no  tension  and  the  parts  to  be  united  have  not  been 
injured.  Either  the  anterior  or  posterior  method  can  be  used  and  the  Mur- 
phy button  or  suture  operation  be  performed.  If  the  patient  is  in  good  con- 
dition and  the  operation  has  been  completed  promptly,  we  prefer  the  pos- 
terior suture  method;  if  the  patient's  condition  is  poor,  the  anterior  button 
operation  is  chosen. 

(E)  Infections.  The  question  of  cancer  infection  grafted  upon  a  raw 
surface  is  an  important  one.  AVe  have  seen  carcinomatous  nodes  develop 
in  the  abdominal  incision,  and  in  the  abdominal  needle  puncture  made  in 
suturing  the  abdominal  wall  after  partial  gastrectomy.  Dissemination  of 
carcinoma  by  rough  handling  or  allowing  infected  cells  to  escape  into  the 
wound  is  not  uncommon.  It  is  for  this  reason  that  all  sections  of  the  dis- 
eased parts  are  made  with  the  actual  cautery,  which  prevents  inoculation  of 
raw  surfaces,  checks  capillary  hemorrhage  and  leaves  the  approximated 
ends  in  an  aseptic  condition  until  they  are  digested  back  to  the  outer  suture 
line.  Pyogenic  infection  is  prevented  by  the  clamps  placed  upon  each  side 
of  the  excised  stomach,  sealing  against  escape  of  contents,  while  the  exposed 
edges  beyond  the  clamp  are  sterilized  by  the  use  of  the  cautery  in  making 
the  section.  In  addition  to  this  the  gauze  pads  are  arranged  in  two  rows, 
an  outer,  deep  layer  which  is  not  changed  until  final  removal,  and  an  inner, 
superficial  layer,  which  is  being  constantly  renewed.  Upon  removal  of  the 
final  gauze  pack  the  entire  field  is  carefully  gone  over  and  any  little  bleeding 
point  checked  by  ligature.  After  sponging  the  surfaces  with  a  moist  saline 
gauze  pad,  the  abdominal  incision  is  closed. 

In  some  cases  drainage  seems  wise  on  account  of  accidental  soiling.  This 
is  seldom  necessary  but  if  in  doubt,  drain,  and  best  with  a  cigarette  drain 
placed  at  the  lower  angle  of  the  external  wound,  entirely  away  from  the 
visceral  suture  lines.  The  internal  end  of  the  drain  should  reach  to  a  situa- 
tion just  above  the  transverse  colon,  which  acts  as  a  dam  when  the  patient 
is  placed  in  the  proper  position  in  bed — head  and  shoulders  elevated.  In 
this  half-sitting  posture  the  little  pouch  formed  by  the  transverse  colon 
is  not  unlike  an  artificial  pelvis  into  which  any  fluids  gravitate.  If  there  be 
but  a  limited  area  to  be  quarantined,  as  from  slow  perforation,  the  drain 
should  be  brought  out  in  the  most  direct  manner  possible. 

(F)  Shock.  If  the  patient  is  in  good  condition  there  is  practically  no 
shock  because  there  is  no  blood  loss  and  little  exposure  of  abdominal  contents. 
The  operation  proceeds  systematically  and  can  be  done  in  a  suitable  case  by 
the  average  operator,  from  the  beginning  of  the  abdominal  incision  until  it  is 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


495 


closed,  in  from  fifty  minutes  to  one  hour  and  fifteen  minutes.  If  the  patient's 
condition  is  very  poor,  owing  to  early  obstruction,  the  chief  danger  comes 
from  the  lack  of  fluids  in  the  body.  As  suggested  to  us  by  Dudley  Allen, 
this  should  be  made  up  by  subcutaneous  infusions  of  saline  solution,  forty 


>-' 


M\ 


1  V 


j- 


Ptlorectomt  with  Partial  Gastrectomt. 

Showing  ligation  of  lesser  and  greater  omentum,  also  application  of  clamps  to  duodenum 
and  to  stomach.     Also  circular  and  end-sutures  of   duodenum  in  place. 
(From  original  drawings  by  Dr.  W.  J.  Mayo.) 


to  sixty  ounces  a  day,  usually  twenty  to  thirty  ounces  every  twelve  hours, 
for  two  days  previous  to  the  operation.  This  is  continued  for  several  days 
following  operation  if  necessary.  In  these  dehydrated  patients  it  is  almost 
impossible  to  get  sufficient  fluids  into  them  in  any  other  manner.  For  sub- 
cutaneous infusions  we  prefer  the  ordinary  Davidson  syringe,  to  which  I 
attach  an  aspirating  needle.     The  hand  bulb  enables  nice  regulation  of  the 


496 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


inflow.  The  whole  can  be  boiled  and  the  infusion  given  by  a  nurse  as  easily 
as  an  enema.  In  debilitated  patients  very  little  anesthetic  is  used,  just 
enough  to  enable  the  surgeon  to  open  and  close  the  abdomen.     All  of  the 


Pylorectomy  with  Partial  Gastrectomy  for  Carcinoma  of  Pylorus. 

Showing  manner  of  closing  end  of  pylorus  and  stomach,  also  ligation  of  all  vessels. 
(From  Dr.  W.  J.  Mayo 's  original  drawing.) 


visceral  work  can  be  done  without  pain.  The  previous  exhibition  of  morphia 
keeps  the  patient  from  becoming  nervous. 

An  enema  of  six  ounces  of  coffee  is  given  as  soon  as  the  patient  is  put  to 
bed.    If  necessary  morphia,  strychnine  and  so  forth  are  exhibited. 

The  after-treatment  is  simple,  the  head  and  shoulders  of  the  patient  are 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


497 


raised  by  four  or  five  pillows,  rectal  alimentation  is  instituted,  hot  water  by 
mouth,  after  twelve  hours,  in  tablespoon  doses,  increased  to  an  ounce  every 
hour.  After  thirty-six  hours  the  usual  experimentation  with  liquid  foods  is 
begun. 

To  recapitulate,  there  are  six  important  stages  to  the  operation  as  out- 
lined : 


Pylorectomy  with  Partial  Gastrectomy  with  Gastro-jejxjnostomy  Operation  Completed. 
(From  Dr.  W.  J.  Mayo's  original  drawing.) 


Step  1. — Open  the  abdomen. 

Biep  2. — Double  ligate  and  divide  the  gastric  artery,  ligate  and  divide 
the  necessary  amount  of  gastro-hepatic  omentum  close  to  the  liver,  leaving 
most  of  its  structure  attached  to  the  stomach.  Double  ligate  and  divide  the 
superior  pyloric  artery  and  free  the  upper  inch  or  more  of  the  duodenum. 

Step  3. — With  the  fingers  as  a  guide  underneath  the  pylorus,  in  the  lesser 


498  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

cavity  of  the  peritoneum,  ligate  the  right  gastro-epiploic  or  gastro-duodenal 
artery  and  progressively  tie  and  cut  away  the  gastro-colic  omentum  distal  to 
the  glands  and  vessels  up  to  the  appropriate  point  on  the  greater  curvature, 
and  here  ligate  the  left  gastro-epiploic  vessels. 

Step  4. — Double  clamp  the  duodenum,  divide  between  with  the  cautery, 
leaving  one-fourth  inch  projection.  With  a  running  suture  of  catgut  through 
the  seared  stump  the  end  of  the  duodenum  is  closed  as  the  clamp  is  removed. 
A  purse-string  suture  about  the  duodenum  enables  the  stump  to  be  inverted. 
The  proximal  end  of  the  stomach  is  double-clamped  along  the  Mikulicz- 
Hartmann  line  and  divided  with  the  cautery,  leaving  one-fourth  inch  projec- 
tion. Suture  through  the  seared  stump  with  a  catgut  button-hole  suture. 
This  is  again  turned  in  after  removal  of  the  clamp  by  a  continuous  silk  or  Gush- 
ing suture. 

Step  5. — Independent  gastro-jejunostomy. 

Step  6. — Closure  of  the  wound. 

The  operation  herein  described,  with  a  mortality  of  one  in  fifteen  should 
be  the  operation  of  choice  for  the  average  case  of  fairly  early  disease  of  the 
pyloric  region. — W.  J.  Mayo,  A.  M.,  M.  D,] 

GASTROPTOSIS 

The  condition  of  gastroptosis  is  rarely  found  except  in  a  complicated  form. 
It  is  usually  associated  with  a  condition  of  general  enteroptosis  in  Avhich  all 
of  the  intra-abdominal  organs  are  more  or  less  prolapsed.  Thus,  for  example, 
when  the  patient  is  in  the  erect  position  the  liver  is  below  the  normal  line ;  the 
kidneys,  especially  the  right  one,  are  lower  than  normal ;  the  transverse  colon, 
cecum  and  small  intestines  are  low  down  in  the  abdomen.  Several  years 
ago  many  of  these  patients  were  subjected  to  a  gastro-enterostomy,  in  the 
hopes  that  gastric  drainage  might  relieve  their  stomach  disturbances,  but  the 
results  were  most  unsatisfactory. 

Patients  suffering  from  gastroptosis  are  usually  thin  and  are  often  tall 
and  nearly  always  of  a  nervous  temperament.  They  complain  of  chronic 
stomach  trouble  characterized  by  discomfort  after  eating,  bloating  and  eruc- 
tation of  gas.  Nausea  and  vomiting  are  not  uncommon,  and  usually  a  stomach 
splash  can  be  found  in  the  lower  portion  of  the  abdomen  several  hours  after 
eating.    Constipation  is  usually  present. 

The  physical  signs  of  gastroptosis  can  easily  be  elicited  by  distending  the 
stomach  with  air  through  a  stomach  tube,  or  by  administering  a  bismuth  meal 
and  taking  an  X-ray  picture. 

Treatment.  The  majority  can  be  greatly  benefited  by  general  treatment, 
such  as  regulating  the  bowels ;  massage  of  the  abdomen ;  gymnastic  exercises 
to  strengthen  the  abdominal  wall;  the  avoidance  of  tight  lacing;  the  admin- 
istration of  tonics ;  giving  a  simple  but  nourishing  diet.  Much  benefit  may 
also  be  derived  by  supporting  the  abdominal  viscera  by  the  wearing  of  a 
well-fitting  abdominal  support. 

In  many  patients  the  palliative  treatment  does  not  give  relief  and  they 
become  emaciated,  suffer  constantly  and  become  chronic  invalids.  In  these 
we  have  to  look  to  some  surgical  procedure  for  relief.  The  object  of  the 
operation  is  to  place  the  stomach  in  its  normal  location  as  nearly  as  possible 
and  retain  it  in  this  position.  This  will  do  away  with  the  dragging  on  the 
gastro-hepatic  omentum  and  overcome  the  obstruction  which  is  usually  pres- 
ent due  to  a  kinking  of  the  duodenum. 

Operative  treatment.  Many  operations  have  been  devised  for  holding  up 
the  stomach,  but  that  of  Beyer  seems  to  be  the  most  satisfactory.  He  shortens 
the  suspensory  ligaments  of  the  stomach  without  interfering  with  its  normal 


SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 


499 


mobility  and  no  abnormal  attachment  is  made  to  the  abdominal  wall.  The 
operation  is  performed  as  follows :  The  patient  placed  in  the  inverted  Tren- 
delenburg position,  and  a  median  incision  is  made  allowing  the  intestines  to 
settle  toward  the  lower  portion  of  the  abdominal  cavity.  The  sutures  used 
should  be  of  some  non-absorbable  material,  as  linen  or  silk.    The  first  suture  is 


Showing  Application  of  Stitches  in  the  Gastro-Hepatic  Ojientum  in  Beyer's  Operation 

FOR  GaSTROPTOSIS. 


introduced,  beginning  above,  in  the  strong  tissue  of  the  attachment  of  the 
ligament  to  the  liver,  the  needle  grasping  a  considerable  bite  of  tissue,  then 
grasps  the  more  delicate  portion  at  short  intervals  from  above  downwards 
until  a  point  just  above  the  gastric  vessels  is  reached  at  the  lesser  curvature. 
Four  to  six  of  these  sutures  are  inserted  in  this  manner  as  shown  in  illustra- 
tion. When  these  sutures  are  tied  the  lesser  curvature  is  carried  up  in  con- 
tact, or  almost  in  contact,  with  the  under  surface  of  the  liver  at  the  attach- 
ment of  the  gastro-hepatic  ligament,  and  is  fixed  in  this  position. 


500  SURGERY  OF  THE  ESOPHAGUS  AND  STOMACH 

The  principle  of  this  operation  is  that  by  placing  interrupted  sutures 
from  above  downward  through  the  gastro-hepatic  omentum,  or  gastro-hepatic 
and  gastro-phrenic  ligaments,  the  normal  ligamentary  supports  of  the  stomach 
are  shortened  and  the  stomach  elevated  to  its  normal  position  without  dis- 
turbing the  physiologic  mobility  of  the  organ.  "With  the  elevation  of  the 
stomach  the  ptosis  of  the  transverse  colon  is  somewhat  corrected. 

After-treatment.  After  the  operation  gastric  lavage  should  be  used  once  or 
twice  a  day  during  the  time  the  patient  is  in  the  hospital,  and  nourishment 
should  be  given  in  the  form  of  concentrated  food  in  small  quantities  to  prevent 
any  gaseous  distension  of  the  stomach  until  the  tissues  have  become  firmly 
fixed.  With  the  stomach  in  this  new  position,  the  condition  for  normal  diges- 
tion will  be  greatly  improved,  and  within  a  few  months  the  patient's  nutrition 
should  be  markedly  better.  Among  these  patients  there  are  many  who  suffer 
from  a  general  neurotic  condition,  and  unless  this  be  due  to  malnutrition  re- 
sulting from  the  gastroptosis,  the  neurotic  state  will  not  be  much  benefited. 

Rovsing's  operation.  Rovsing's  operation  consists  in  fastening  the  ante- 
rior wall  of  the  stomach  to  the  anterior  abdominal  wall  at  as  near  its  normal 
position  as  possible. 

A  median  incision  is  made  from  the  ensiform  cartilage  to  the  umbilicus. 
The  stomach  is  delivered  into  the  wound,  and  its  anterior  wall  is  grasped  by 
four  mouse-toothed  forceps,  one  forcep  being  applied  to  the  edge  of  the  les- 
ser curvature  about  six  cm.  from  the  pylorus,  the  second  one  to  the  lesser 
curvature  about  ten  em.  distant  from  the  first,  and  the  other  two  being 
applied  at  corresponding  points  near  the  edge  of  the  greater  curvature.  The 
parallelogram  formed  by  these  forceps  indicates  the  portion  of  the  stomach 
to  be  fastened  to  the  abdominal  wall.  A  heavy  silk  suture  is  now  inserted  at 
the  point  of  the  upper  forcep  on  the  lesser  curvature  and  carried  along  the 
lesser  curvature  to  the  point  of  the  other  forcep  near  the  pylorus.  This  stitch 
picks  up  the  peritoneal  and  muscular  coats  of  the  stomach  at  intervals  of  one 
cm.  Four  similar  sutures  are  applied  along  the  anterior  wall  of  the  stomach 
parallel  to  the  first  one,  the  last  extending  between  the  two  forceps  on  the 
greater  curvature.  These  sutures  are  now  passed  up  through  the  abdominal 
wall  on  the  abdomen,  the  sutures  from  the  cardiac  end  of  the  stomach 
emerge  from  the  abdomen  about  seven  cm.  to  the  left  of  the  median  line  and 
the  others  about  three  cm.  to  the  right.  The  sutures  are  so  placed  that  those 
to  the  left  side  are  at  a  higher  level  than  those  from  the  pyloric  end  of  the 
stomach,  this  will  attach  the  stomach  in  a  slanting  position  downwards  from 
left  to  right.  The  peritoneal  surface  is  now  slightly  scarified  and  the  abdom- 
inal incision  closed.  A  glass  plate  about  ten  cm.  square  is  wrapped  with 
sterile  gauze  and  placed  opposite  the  stomach  and  the  five  silk  sutures  are  tied 
together  across  this  plate.    These  sutures  are  left  in  place  about  three  weeks. 

The  authors  have  performed  the  Rovsing  operation  in  three  cases  in  which 
it  was  possible  to  make  fluoroscopic  examinations  at  various  intervals.  In  two 
of  these  cases  the  former  condition  of  gastroptosis  had  recurred  within  one 
year  after  the  operation.  In  the  third  case,  the  stomach  has  remained  in  good 
position  during  a  period  of  three  years. 


PART  VII 

SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

In  considering  the  etiology  of  gall  bladder  disease  it  is  important  to  bear 
in  mind  the  anatomical  relations  and  the  mechanical  provisions.  So  long  as 
the  anatomical  relations  are  normal,  and  the  organ  is,  mechanically  considered, 
approximately  perfect,  there  is  no  occasion  for  treatment  because  the  gall 
bladder  becomes  distended  with  bile,  which  is  a  non-irritating  fluid  and  is 
emptied  regularly.  These  functions  give  rise  to  neither  pain,  irritation  or 
discomfort. 

Normally  the  gall  bladder  is  suspended  from  the  under  surface  of  the 
liver  as  a  very  slightly  distended,  pyriform  sac  which  empties  its  fluid  rap- 
idly into  the  duodenum.  The  muscles  of  the  gall  bladder  are  very  active  and 
well  able  to  expel  the  contents. 

Function.  The  theory  that  the  gall  bladder  serves  the  purpose  of  collect- 
ing bile  during  the  intervals  between  the  taking  of  food,  and  that  this  bile 
is  then  forced  into  the  duodenum  during  the  time  that  the  food  passes  from 
the  stomach  through  this  organ,  has  been  questioned  of  late  because  of  the  fact 
that  no  satisfactory  proof  has  been  produced  for  this  theory,  because  of  the 
fact  that  patients  whose  gall  bladders  have  been  removed  surgically  do  not 
suffer  in  any  way  because  of  its  absence,  and  because  of  the  further  fact  that 
the  amount  of  bile  that  can  be  accumulated  in  the  gall  bladder  is  very  small 
compared  with  the  amount  of  bile  that  is  secreted  during  the  time  the  food 
passes  through  the  duodenum. 

These  arguments  and  others  have  been  advanced  with  an  air  of  scientific 
superiority  overlooking  the  point  that  it  is  quite  logical  to  consider  our 
inability  to  recognize  definite  proofs  of  a  function  as  a  valid  reason  for  dis- 
puting a  function.  Consequently,  it  seems  far  more  scientific  to  await  further 
research  before  we  accept  the  theory  that  the  gall  bladder  has  no  value  from 
the  standpoint  of  physiology. 

Etiology.  It  seems  to  have  been  proven  beyond  a  doubt  that  this  pouch 
shares  the  fate  of  all  similarly  constructed  organs  in  the  body — the  stomach, 
the  urinary  bladder,  the  pelvis  of  the  kidney,  the  vermiform  appendix;  so 
long  as  there  is  nothing  to  prevent  these  organs  from  emptying  their  con- 
tents they  are  almost  certain  to  remain  normal,  but  so  soon  as  obstruction 
occurs,  interfering  with  the  natural  drainage  of  the  organ,  trouble  is  likely  to 
ensue.  In  other  words,  an  interference  with  drainage  is  sure  to  cause  a  certain 
amount  of  residual  substance  which  makes  the  accumulation  of  bacteria  pos- 
sible, and  from  this  accumulation  we  must  expect  injury  to  the  lining  of  tlie 
gall  gladder. 

In  ordinary  health  it  is  probable  that  in  the  majority  of  cases  the  human 
bile  is  sterile.  The  bile  remains  sterile,  however,  only  as  long  as  it  flows 
unobstructed  through  the  ducts.  It  has  been  shown  experimentally  that  as 
soon  as  the  outward  flow  of  bile  has  been  obstructed  by  ligature  of  the  com- 
mon duct,  the  bile  above  the  obstruction  becomes  infected. 

Bacteria  enter  the  gall  bladder  chiefly  in  two  ways :  1.  Along  the  com- 
mon duet  from  the  duodenum.     2.  By  the  blood  current,   chiefly  from  the 

501 


502  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

portal  vein.  The  bacillus  coli,  the  typhoid  bacillus,  and  the  streptococcus  are 
the  most  common  bacterial  inhabitants  of  the  gall  bladder  and  of  gall  stones. 

The  injury  that  results  from  the  accumulation  of  bile  in  the  gall  bladder 
may  simply  be  catarrhal  at  first,  but  will  later  become  destructive  to  the 
mucous  membrane,  giving  rise  to  ulceration;  this  in  turn  will  result  in  cica- 
tricial contraction,  and  this  in  further  obstruction.  In  such  manner  the  con- 
dition must  progress. 

In  the  meantime  the  mucous  and  debris  in  the  gall  bladder  may  have  been 
moulded  into  gall  stones  by  contraction  of  the  gall  bladder  and  thus  give  rise 
to  another  important  element.  The  lining  of  the  gall  bladder  is  now  no  longer 
in  contact  only  with  the  relatively  non-irritating  bile,  but  also  with  these 
hard  bodies,  which  are  often  of  very  irregular  form,  consequently  having  sharp 
angles  or  projections. 

The  location  of  the  impacted  stone  can  frequently  be  determined  from  the 
sj'mptoms.  If  the  increase  in  pain  is  accompanied  by  a  chill,  the  impaction 
is  usually  lower  than  the  neck  of  the  gall  bladder.  A  stone  impacted  in  the 
neck  of  the  gall  bladder  may  cause  a  distension  of  the  gall  bladder  with  serum 
more  or  less  purulent  in  character.  A  gall  bladder  under  this  condition  may 
acquire  a  large  size,  although  usually  this  distension  itself  causes  the  stone 
to  become  dislodged  and  to  fall  back  into  .the  gall  bladder,  and  thus  permits 
the  bile  to  be  evacuated  through  the  cystic  duct.  But  as  long  as  the  stone 
is  not  impacted  in  the  cystic  duct  or  in  the  common  duct,  a  chill  is  not  likely 
to  occur,  because  the  infection  accompanying  the  impaction  does  not  reach 
any  of  the  lymph  nodes  which  are  located  farther  down.  If  the  stone  is  located 
in  the  cystic  duct  or  in  the  common  duct  there  is  likely  to  be  a  fairly  high 
leucocytosis. 

Clinical  experience  has  shown  that  the  above  theory  is  correct,  because 
in  most  of  our  cases  there  has  been  a  distinct  interference  with  drainage 
of  the  gall  bladder.  In  many  cases  this  was  caused  by  a  drawing  down  of  the 
viscus  by  adhesions  to  the  omentum  or  transverse  colon,  or  both,  probably 
caused  by  a  peritonitis  resulting  from  a  perforative  appendicitis  which  the 
patient  had  sustained  many  years  before.  In  other  cases  there  was  a  pedun- 
culated gall  bladder,  which  has  been  attributed  to  the  effects  of  tight  lacing, 
and  as  in  many  cases  this  condition  occurred  onl,y  in  women,  it  seems  possible 
that  this  view  is  correct. 

Concomitant  conditions.  It  has  been  found  that  bacteria,  especially  the 
colon  bacillus,  are  present  with  great  regularity  in  diseased  gall  bladders  and 
in  gall  stones.  It  has  been  found  that  a  large  proportion  of  gall  stone  patients 
previously  suffered  from  typhoid  fever,  and  we  have  found  that  more  than 
thirty-five  per  cent,  of  our  cases  suffered  from  acute  or  chronic  appendicitis. 
It  is  difficult  to  determine  w^hether  typhoid  fever,  disease  of  the  gall  bladder, 
and  of  the  appendix  in  appendicitis,  is  simply  a  simultaneous  infection  or 
whether  the  infection  of  the  gall  bladder  is  secondary  to  the  other  infections. 

In  experiments  upon  animals  it  has  been  found  that  the  simple  infection 
of  the  gall  bladder  gives  rise  to  no  pathological  condition,  provided  there  is 
no  obstruction  to  the  biliary  or  cystic  duct.  The  constant  flow  of  new  bile 
seems  to  be  sufficient  to  dilute  and  wash  away  the  infectious  material  to  a  suffi- 
cient extent  to  make  the  infection  harmless. 

Obstruction.  It  is  quite  different  as  soon  as  there  is  an  obstruction  to  the 
ducts.  Where  there  is  residual  bile  in  wTiich  micro-organisms  can  multiply,  a 
pathological  condition  wall  ensue  which  may  simply  develop  into  a  catarrhal 
inflammation  of  the  mucous  lining  of  the  gall  bladder,  or  it  may  result  in  the 
formation  of  gall  stones,  or  in  a  severe  inflammation  of  the  gall  bladder  in- 
volving anatomical  structures  beyond  the  mucous  membrane.  In  man  this 
obstruction  may  result  from  the  inflammation  of  the  mucous  membrane  of 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER  503 

the  common  duct  due  to  an  infection  from  the  alimentary  canal,  or,  as  we 
have  seen  in  a  number  of  cases,  the  gall  bladder  may  be  drawn  downward 
by  adhesions,  causing  a  short  bend  in  the  common  duct,  or  more  usually  in 
the  cystic  duct;  or  an  adhesion  between  the  duodenum,  stomach  and  liver. 
This  condition  is  often  due  to  a  gastric  or  duodenal  ulcer.  Again,  the  gall 
bladder  may  be  forced  down  out  of  its  normal  position  on  account  of  tight 
lacing,  and  the  mucus  and  debris,  accumulated  in  the  pouch  containing  resid- 
ual bile,  may  be  expelled  at  intervals  and  may  clog  the  biliary  or  the  com- 
mon duct,  and  thus  form  the  obstruction  necessary  to  make  the  infective  ma- 
terial effective.  "We  have  repeatedly  observed  a  complete  obstruction  of  the 
common  duct  produced  in  this  manner.  Moreover,  we  have  observed  some  of 
the  most  violent  paroxysms  of  gall  stone  colic  in  cases  of  this  kind. 

If  this  obstruction  persists  in  the  presence  of  infectious  material  in  the 
gall  bladder  a  suppurative  inflammation  may  ensue  and  this  may  result  in 
an  empyema  of  the  gall  bladder ;  if  the  infection  is  severe,  especially  if  there 
be  present  a  spasmodic  contraction  of  the  gall  bladder,  the  entire  mucous  lin- 
ing of  the  latter  may  become  gangrenous,  a  condition  which  we  have  repeat- 
edly seen  in  acute  cases.  This  may  in  turn  extend  to  the  other  layers  of 
the  gall  bladder,  resulting  in  a  gangrene  of  the  entire  organ,  or  it  may  affect 
only  a  small  portion  of  the  gall  bladder.  When  this  is  the  case,  the  con- 
traction of  the  non-affected  portion  of  the  gall  bladder  is  likely  to  cause  a 
perforation  at  the  gangrenous  point. 

It  is  of  practical  importance  to  know  that  these  spasmodic  contractions 
of  the  gall  bladder  correspond  with  contractions  of  the  stomach  and  that  they 
will  subside  when  the  stomach  is  at  rest,  only  to  recur  when  this  condition 
of  rest  in  the  stomach  is  interrupted. 

Age  and  sex  undoubtedly  have  some  influence  upon  the  formation  of  gall 
stones,  most  often  found  in  middle  adult  life.  In  looking  over  a  series  of 
several  hundred  of  our  own  cases  it  was  found  that  the  average  age  at  the 
time  of  operation  was  forty-six  years,  and  that  the  average  duration  of 
symptoms  as  given  in  the  histories  was  six  and  one-half  years.  The  condi- 
tion occurred  four  times  oftener  in  females  than  in  males.  The  youngest 
male  patient  operated  upon  by  the  authors  was  twenty  years  of  age,  and  the 
youngest  female  was  ten  years  old. 

Symptoms  and  signs  of  gall  bladder  disease.  The  frequency  with  which 
gall  stones  are  overlooked  draws  our  attention  to  the  fact  that  it  will  be  neces- 
sary to  change  the  basis  of  our  diagnosis,  because  the  old  plan  must  continue 
to  result  in  wrong  conclusions. 

In  studying  the  histories  of  a  series  of  gall  stone  cases  it  will  be  found 
that  the  early  manifestations  of  the  presence  of  gall  stones  will  practically 
never  be  referred  by  the  patient  to  the  region  of  the  gall  bladder  or  bile  ducts. 
The  patients  refer  their  trouble  to  the  region  of  the  stomach  and  not  to  the 
liver. 

Perhaps  the  earliest  symptom,  which  has  persisted  for  years,  is  "indiges- 
tion." It  is  not  uncommon  for  these  patients  to  come  to  the  surgeon  with 
a  diagnosis  of  an  attack  of  indigestion,  gastric  catarrh,  neuralgia  of  the 
stomach,  spasms,  etc. 

The  symptoms,  complications  and  dangers  of  gall  stones,  differ  greatly 
according  to  the  location  of  the  stones  in  the  gall  bladder,  cystic  or  common 
ducts. 

Gall  stones  in  the  gall  bladder,  in  the  absence  of  infection,  may  produce 
so  little  discomfort  that  they  may  persist  for  years  without  being  discov- 
ered. As  soon  as  catarrh  or  some  acute  infection  occurs,  or  the  stone  passes 
from  the  gall  bladder  into  the  cystic  duct,  there  may  be  a  great  variety  of 


504  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

symptoms,  varying  from  mere  spasms,  frequently  called  attacks  of  "indiges- 
tion," to  very  severe  colic,  agonizing  in  character,  so  severe  as  to  even  lead  to 
collapse. 

Pain  to  be  distinguished  from  colic  may  be  local  or  referred.  The  local 
pain  may  be  dull  in  character,  rather  diffuse,  and  exaggerated  upon  taking 
food.  It  is  this  variety  of  pain  which  is  apt  to  be  mistaken  for  that  due  to 
disease  of  the  stomach.  The  dull  pain  is  usually  due  to  some  irritation  or 
inflammation  of  the  gall  bladder  becoming  more  or  less  tense  by  some  obstruc- 
tion to  the  cystic  duct  due  to  an  impaction  of  a  stone  in  the  cystic  duct  in 
its  attempt  to  escape  from  the  gall  bladder,  or  to  an  inflammatory  state  of  the 
gall  bladder  interfering  with  the  free  exit  of  bile. 

An  important  sign.  Tenderness  is  always  present  especially  on  deep  pres- 
sure. One  of  the  most  constant  signs  of  gall  bladder  disease  is  the  inability 
of  the  patient  to  take  a  full  inspiration  when  the  physician's  fingers  are  placed 
up  underneath  the  costal  arch  in  the  region  of  the  ninth  or  tenth  ribs.  The 
diaphragm  forces  the  liver  down  until  the  sensitive  gall  bladder  reaches  the 
examining  fingers  when  the  inspiration  suddenly  ceases  as  though  it  had 
been  shut  oft". 

The  pain  is  frequently  more  acute  than  that  described  above,  which  means 
that  there  is  a  more  marked  irritation  and  inflammation  of  the  gall  bladder 
or  its  ducts,  and  perhaps  of  the  surrounding  peritoneum. 

The  pain  may  be  referred  to  various  regions.  It  frequently  radiates  to  the 
right  subscapular  region  and  occasionally  to  the  left ;  to  the  epigastric  region 
or  umbilicus ;  to  the  front  of  the  chest  and  neck  or  down  the  arm. 

Boas  has  described  the  existence  of  an  area  of  referred  tenderness  which 
is  present  in  the  majority  of  patients  suffering  from  gall  bladder  disease. 

To  demonstrate  this  area  the  finger  should  be  pressed  against  a  point  to 
the  right  of  the  tenth  dorsal  spine ;  then  against  successive  points  in  lines 
running  horizontally  outwards,  opposite  the  other  spinous  processes.  It  will 
then  be  evident  which  side,  if  either,  is  the  more  tender. 

Colic.  Colic  in  gall  stone  disease  is  not  as  common  as  formerly  supposed. 
We  have  found  that  over  one-half  of  our  cases  have  never  experienced  severe 
biliary  colic. 

The  colic,  when  severe,  causes  the  most  intense  suffering.  It  comes  on 
suddenly  and  not  infrequently  produces  a  condition  of  collapse.  The  patient 
is  cold  and  yet  has  profuse  sweating. 

The  location  of  the  pain  differs  greatly.  When  the  colic  is  due  to  a  spasm 
of  the  gall  bladder  or  cystic  duct  it  is  most  apt  to  begin  along  the  right 
costal  margin  and  radiate  to  the  right  subscapular  region.  When  due  to 
spasm  of  the  common  duct  it  is  more  apt  to  be  located  centrally  and  radiate 
to  the  mid-scapular  region.  It  may  be  epigastric  throughout,  or  may  even  be 
situated  in  the  left  upper  quadrant  of  the  abdomen. 

The  cause  of  gall  stone  colic  has  been  much  discussed,  yet  there  seems 
to  be  no  present  agreement  upon  this  subject. 

Considering  the  abruptness  with  which  these  colics  begin,  and  the  sud- 
denness in  their  relief,  it  would  seem  more  probable  that  the  pain  was  due 
to  a  spasm  of  the  gall  bladder  or  its  ducts  during  the  attempt  at  expulsion 
of  a  calculus,  -or  thick  bile,  sand  or  mucus.  This  suddenness  with  which  the 
pain  begins  and  subsides  is  certainly  incompatible  with  anything  of  an 
inflammatory  nature,  and  can  only  be  explained  by  a  spasm  due  to  the  sudden 
entrance  and  exit  of  some  foreign  body. 

Coincidence  between  stomach  and  gall  bladder  contractions.  It  is  of  prac- 
tical interest  to  know  that  these  spasmodic  contractions  of  the  gall  bladder 
correspond  with  the  contraction  of  the  stomach  and  that  they  will  subside 


SURGERY  OF  THE  Gi^LL  BLADDER  AND  LIVER  505 

when  the  stomach  is  at  rest,  only  to  recur  when  this  condition  of  rest  in  the 
stomach  is  altered. 

We  have  repeatedly  observed  that  attacks  of  gall  stone  colic,  which  wonld 
not  subside  from  the  use  of  as  much  as  one-half  to  three  quarters  of  a  grain 
of  morphine  given  hypodermically,  stop  directly  upon  irrigating  the  stomach 
with  very  hot  water,  thus  putting  the  organ  at  rest,  only  to  have  a  recur- 
rence the  moment  any  form  of  food  was  taken,  giving  rise  to  the  normal  con- 
traction. In  these  cases  a  renewed  use  of  gastric  lavage  and  further  abstain- 
ing from  food  would  result  in  permanent  interruption  of  the  spasmodic  con- 
traction of  the  gall  bladder.  This  point  is  of  practical  importance,  because  it 
not  only  indicates  an  efficient  means  for  securing  the  relief  of  pain,  but  also 
for  preventing  destruction  of  gall  bladder  tissue  and  possible  perforation. 

Stomach  symptoms.  Perhaps  the  most  common,  as  well  as  earliest  symptom 
of  gall  stone  disease  is  "indigestion."  The  attacks  of  indigestion  begin  with 
pain  in  the  epigastrium,  followed  by  nausea  and  finally  vomiting,  which  usu- 
ally brings  relief.  The  nausea  and  vomiting  are  parth"  reflex  in  character 
and  partly  due  to  direct  irritation. 

Other  gastric  disturbances  associated  with  gall  bladder  disease  are  fre- 
quently manifested  by  distress  in  the  epigastric  region,  described  as  a  feeling 
of  weight  or  a  burning  sensation  after  eating ;  also  gaseous  distension  of  the 
abdomen.  These  patients  are  also  usually  troubled  with  eructations  of  gas 
after  eating.  It  is  not  uncommon  for  these  patients  to  have  repeated  attacks 
of  nausea  and  vomiting  and  attacks  of  indigestion  accompanied  by  a  severe 
pain  in  the  epigastrium,  often  called  gastralgia  or  neuralgia  of  the  stomach. 

After  an  attack  of  nausea,  vomiting  and  epigastric  pain  there  is  apt  to 
be  an  interim  when  the  patient  is  free  from  stomach  symptoms,  or  has  only 
the  milder  symptoms  of  bloating  and  distress  after  eating. 

There  may  be  a  dull  pain  beginning  in  the  epigastric  region  and  extending 
around  the  right  side  at  about  the  level  of  the  tenth  rib,  passing  to  a  point 
near  the  spine  and  progressing  upwards  underneath  the  right  shoulder  blade. 

Jaundice.  This  condition,  upon  which  so  much  stress  has  been  placed  in 
the  diagnosis  of  gall  stones,  is  absent  in  the  greater  number  of  cases.  Our 
experience  has  been  that  only  a  small  proportion  have  ever  been  severely 
jaundiced,  and  in  more  than  one-half  of  them  jaundice  has  never  been  observed. 

The  idea  in  regard  to  icterus  in  connection  with  gall  stones  has  been  handed 
down  to  successive  generations  of  phj^sicians  and  the  laity  so  long,  that  the 
majority  of  patients  refuse  to  believe  that  they  could  have  gall  stones  and  not 
be  jaundiced. 

Jaundice  in  cholelithiasis  is  due  to  an  impaction  of  a  stone  in  the  common 
or  hepatic  ducts,  or  an  infection  of  these  ducts,  and  occasionally  to  an  im- 
paction of  a  large  stone  in  the  cystic  duct  pressing  upon  the  common  or  hepa- 
tic ducts. 

"When  jaundice  is  due  to  gall  stones  it  is  most  always  preceded  by  a  colic. 
The  colic  may  come  on  a  few  hours  or  days  before  the  appearance  of  the 
jaundice.  The  yellow  tinge  as  a  rule  comes  on  gradually  and  increases  until 
the  obstruction  is  relieved,  and  then  gradually  disappears. 

Remittent  icterus,  slight,  or  as  might  be  called,  incomplete  attacks  of 
icterus,  occurring  as  often  as  once  or  twice  a  week,  is  characteristic  of  stone 
in  the  common  duct.  Fenger  attributed  this  condition  to  a  floating  chole- 
dochus-stone.  He  described  this  condition  as  occurring  in  the  following  man- 
ner :  A  stone  becomes  impacted  in  the  common  duct,  and  the  accumulation  of 
bile  on  the  proximal  or  liver  side,  presses  the  walls  of  the  duct  away  from  the 
stone,  allowing  the  bile  to  pass  around  the  stone.  Following  this  the  remittent 
jaundice  is  due  to  a  "ball-valve"  action  of  the  stone. 

When  jaundice  is  due  to  a  carcinoma  involving  the  gall  ducts,  or  from 


506  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

pressure  from  a  growth  of  the  head  of  the  pancreas,  the  jaundice  will  appear 
gradually  and  without  pain.  There  will  be  no  remission  or  intermission,  but 
it  Avill  steadily  deepen  from  day  to  day  until  the  skin  becomes  a  greenish-yel- 
low color.  It  is  very  rare  to  meet  with  jaundice  of  a  deep,  greenish-yellow 
color,  except  in  the  presence  of  malignant  disease. 

Fever  is  not  ordinarily  present  early  in  a  simple  attack  of  gall  stones.  If 
the  attack  is  prolonged  and  infection  occurs,  temperature  develops.  When 
the  infection  is  confined  entirely  to  the  gall  bladder,  the  rise  of  temperature 
is  usually  not  high.  Mayo  explains  this  condition  by  the  fact  that  there  are 
few  lymphatic  channels  in  the  gall  bladder  and  consequently  slow  absorption. 

Where  there  is  an  infection  of  the  ducts  there  may  be  rigor  accom- 
panying or  following  the  colic,  with  a  very  abrupt  rise  of  temperature  to  its 
maximum,  and  then  with  almost  equal  rapidity  a  return  to  normal.  These 
attacks  may  simulate  a  malarial  infection.  Between  the  attacks  of  infection 
the  temperature  remains  practically  normal.  Persistent  fever  associated  with 
other  gall  stone  symptoms  may  mean  an  empyema,  or  severe  cholecystitis 
or  an  extension  of  the  infection  to  the  channels  in  the  liver. 

Tumor.  A  palpable  enlargement  of  the  gall  bladder  occurs  as  the  result 
of  some  obstruction  of  the  cystic  duct.  This  obstruction  may  be  from  an 
impacted  stone,  a  cicatricial  contraction  of  the  cystic  duct,  a  twist  of  the  neck 
of  the  gall  bladder,  or  from  an  abnormal  growth.  It  occurs  also  when  there  is 
an  obstruction  of  the  common  duct  caused  by  some  pressure  from  outside. 

An  enlarged  gall  bladder  is  generally  pear-shaped,  lies  just  below  the  edge 
of  the  liver  and  moves  up  and  down,  during  the  act  of  respiration,  with  the 
liver. 

Occasionally,  through  a  relaxed  abdomen,  one  can  directly  palpate  the 
stones  within  a  gall  bladder. 

Diverticulum  of  the  gaU-bladder  perforating  the  liver.  Anomalies  of  the 
gall-bladder  are  comparatively  rare  and  but  very  few  references  to  such  cases 
can  be  found  in  the  literature.  An  anomalous  gall-bladder  complicated  with 
disease  and,  necessitating  a  surgical  removal,  was  recently  encountered  in 
our  clinic. 

In  Piersol's  "Human  Anatomy''  the  following  statement  is  made  regarding 
abnormalities  of  the  gall-bladder:  "The  gall-bladder  may  be  absent,  as  is 
normally  the  case  in  some  of  the  lower  animals :  it  may  be  congenitally  of 
hour-glass  shape ;  it  may  be  bifid ;  it  may  communicate  directly  with  the  liver 
by  an  hepatocystic  duct ;  or  it  may  be  transposed  in  conjunction  with  other 
viscera." 

Rolleston,  in  his  monograph  on  "Diseases  of  the  Liver,  Gall-Bladder  and 
Bile-Ducts,"  mentions  several  anomalies  and  gives  a  reference  to  F.  Deve. 
The  latter  author  is  the  only  one,  so  far  as  we  could  determine,  who  has  de- 
scribed a  condition  similar  to  the  case  which  follows. 

A  Finnish  housemaid,  age  twenty-nine,  was  admitted  to  the  hospital  on  September  1st, 
1916.  Her  family,  past  and  menstrual  histories  were  negative.  She  had  had  measles  as  a 
child  and  does  not  think  she  ever  had  any  other  illness.  She  was  never  injured.  In  Decem- 
ber, 1915,  the  mastoid  cells  on  the  right  side  were  drained,  and  the  tonsils  were  removed. 

Present  complaint.  In  July,  1916,  she  had  an  attack  of  pain  in  the  right  lower  quadrant 
which  was  transmitted  to  the  epigastrium.  At  that  time  she  complained  of  marked  tenderness 
in  the  light  lower  quadrant.  She  was  not  nauseated  nor  did  she  vomit  and  the  attack  termi- 
nated four  days  later.  She  was  not  jaundiced  at  this  time.  She  has  never  been  entirely  free 
from  this  pain,  however,  and  on  August  31st,  1916,  the  pain  became  much  more  severe.  She 
did  not  vomit  and  was  not  nauseated  until  September,  1916.  The  appetite  was  poor  and 
food,  exercise,  and  riding  on  street  cars  increased  the  pain.  There  were  no  symptoms  sug- 
gestive of  urinary  disturbance.  She  was  moderately  constipated,  requiring  the  use  of  cathar- 
tics twir-e  a  week,  and  stated  emphatically  that  she  had  never  had  abdominal  distress  previous 
to  the  attack  described. 

Physical  examination  was  entirely  negative  except  for  the  abdomen,  where  there  was 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


507 


moderate  tenderBess  elicited  over  McBuriiey's  point  and  just  beneath  tlie  costal  border  in  the 
right  niid-clavicular  line.     There  was  slight  spasm  also  oyer  McBurney 's  point. 

Clinical  diagnosis.     Chronic  appendicitis;   cholecystitis. 

Operation.  On  September  2nd,  1916,  following  the  usual  laparotomy  preparations,  an 
upper  right  rectus  incision  was  made.  The  liver  was  in  its  normal  position,  and  on  its  sur- 
face, 1.5  cm.  from  the  edge  nearest  the  gall-lilndder,   was  seen  a  circular,  bluish  white  cyst 


1 


-'-  Cyst- like 
of  aiverlictxlum. 


olon 


-<3T- 


Fig.  1.    Diverticulum  of  the  Gall-Bladder  (Surface  View).     The  Fundus  of  the  Gall- 
bladder Is  Seen  in  Its  Normal  Eelation  to  the  Liver. 
Fig.  2.     Cross  Section  Showing  Shape  of  Diverticulum. 
Fig.  3.    "Punched-Out"  Cylindrical  Opening  in  Liver  After  Cholecystectomy. 

2  cm.  in  diameter  (Fig.  2).  This  cyst  contained  fluid  and  was  continuous  with  a  circular 
opening  in  the  liver.  The  gall-bladder  was  found  somewhat  large  and  distended  and  there 
were  found  numerous  firm  adhesions  between  its  fundus  and  the  colon.  Adhesions  between 
the  duodenum  and  cystic  duct  caused  a  sharp  kinking  of  the  duct,  which  was  partially 
relieved  by  section  of  the  adhesions. 

Because  of  the  marked  evidences  found  of  pericholecystitis  and  of  obstruction  to  the 
bile-duct,  it  was  deemed  advisable  to  remove  the  gall-bladder.  The  cystic  duct  and  cystic 
vessels    were    clamped    separately,    sectioned    and    ligated.      The    gall-bladder    was    stripped 


508  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

from  the  liver  from  below  upwards,  and  it  was  while  doing  this  procedure  that  it  was  noted 
that  the  apparent  * '  cyst ' '  in  the  liver  communicated  with  the  gall-bladder,  as  shown  in  Fig. 
2.  The  entire  gall-bladder,  with  its  diverticulum,  was  removed,  leaving  a  "  punched-out" 
cylindrical  opening  in  the  liver  (Fig.  3).  The  gall-bladder  contained  yellowish  stained  mucoid 
material  and  the  mucosa  was  reddened,  edematous  and  rugged,  suggestive  of  chronic  inflamma- 
tion. The  appendix  was  found  somewhat  enlarged  at  its  distal  end,  and  there  was  a  partial 
constriction  1  cm.   from  the  cecal  end.     The  appendix  was  removed. 

This  is  undoubtedly  a  congenital  anomaly  of  the  gall-bladder,  since  no  evidences  of 
severe  inflammation  nor  injury  were  found  in  this  region. 

Etiology.  It  is  difficult  to  ascribe  a  cause  for  this  condition,  since  in  the  study  of 
comparative  anatomy  there  have  been  found  no  real  perforations  of  the  liver  by  the  gall- 
bladder. Deve  thinks  that  the  condition  is  due  to  the  fusion,  in  embryonic  life,  of  the  two 
lobar  surfaces  of  a  deep  incisura.  In  a  systematic  post-mortem  examination  of  130  children 
of  all  ages,  he  found  a  completely  perforating  gall-bladder  in  one  case  and  partial  perfora- 


Gall-Bladder  Removed  in  a  Case  of  Perforating  Hernia  of  the  Gall-Bladder  Through 

THE  Liver. 

tions  in  two  cases.  In  eight  other  instances  he  found  the  fundus  of  the  gall-bladder  more  or 
less  embedded  in  the  liver.  He  never  found  the  condition  in  adults,  which,  he  thinks,  is  due 
to  pressure  atrophy  of  the  hepatic  bridge  from  pressure  of  the  abdominal  wall  and  of  a 
distended  gall-bladder. 

OBSTRUCTION  OF  THE  CYSTIC  DUCT 

Obstruction  of  the  cystic  duct  causes  retention  of  fluid  in  the  gall  blad- 
der with  a  rapid  distension  thereof  behind  the  obstruction.  This  fluid  con- 
sists of  mucus  if  the  infection  is  slight,  or  of  muco-pus  if  the  infection  is  more 
severe.  The  bile  that  may  be  in  the  gall  bladder  at  the  time  the  obstruction 
occurs  is  rapidly  absorbed,  leaving  either  the  clear  mucus  or  turbid  fluid, 
according  to  the  amount  of  infection.  The  distended  gall  bladder  may  reach 
an  enormous  size  and  usually  becomes  palpable.  If  the  inflammatory  process 
be  very  acute  a  severe  cholecystitis  or  even  gangrene  of  the  gall  bladder  may 
result.  Associated  with  this  condition  a  local  protective  peritonitis  usually 
develops  leading  to  the  formation  of  visceral  adhesions. 

The  early  symptoms  of  impaction  of  stone  in  the  cystic  duct  are  usually 
very  acute,  beginning  with  a  severe  colic  underneath  the  right  costal  arch, 
and  radiating  up  into  the  right  subscapular  region.  There  is  rarely  any  jaun- 
dice accompanying  or  following  the  pain.  The  pain  loses  its  colicky  character 
rather  early  and  there  may  be  only  a  dull  ache  or  sense  of  discomfort.  If  the 
obstruction  becomes  chronic  and  there  is  little  or  no  infection,  a  hydrops  of 
the  gall  bladder  develops.  If  it  is  associated  with  infection  of  any  severity, 
an  empyema  of  the  gall  bladder  is  apt  to  be  the  result. 

All  of  these  symptoms  may  occur  without  any  evidence  of  jaundice. 


SUEGERY  OF  THE  GALL  BLADDER  AND  LIVER      509 
ACUTE  CHOLECYSTITIS 

The  symptoms  found  in  an  acute  cholecystitis  are  similar  to  those  present 
in  the  early  stages  of  cholelithiasis.  In  addition  to  these  there  is  an  enlarge- 
ment of  the  gall  bladder,  often  making  it  palpable  and  very  tender  upon 
pressure.  There  is  often  acute,  severe  pain  in  the  gall  bladder  which  may 
radiate  to  the  back,  chest  or  abdomen.  Associated  with  the  pain  and  tender- 
ness there  may  be  a  right-sided  rigidity  which  may  simulate  appendicitis. 
The  history  will  help  in  the  diagnosis,  as  it  will  be  found  that  the  pain  was 
originally  in  the  gall  bladder  region  and  later  became  diffused.  As  a  rule 
the  tenderness,  pain  and  rigidity  of  the  abdomen  are  limited  to  an  area  along 
the  costal  margin. 

CHRONIC  CHOLECYSTITIS 

In  chronic  cholecystitis  there  is  seldom  present  a  definite  train  of  symp- 
toms which  would  ordinarily  direct  one's  attention  to  the  gall  bladder.  How- 
ever, there  is  usually  present  a  rather  constant,  dull,  aching  pain  in  the  right 
hypochondrium,  often  hardly  noticeable.  There  may  be  exacerbations  of  the 
inflammatory  trouble  when  the  pain  will  be  more  marked.  The  principal  symp- 
toms will  be  in  the  line  of  digestive  disturbances,  manifested  by  a  sensation  of 
fullness  in  the  epigastrium,  more  or  less  bloating  and  distress  coming  on  during 
or  immediately  after  eating,  accompanied  by  eructations  of  gas.  It  is  not  un- 
common for  these  patients  to  complain  of  "sour"  stomach. 

Occasionally  these  cases  will  suffer  from  a  typical  attack  of  biliary  colic 
from  the  passage  of  sand-like  material  through  the  gall  ducts.  It  is  not  un- 
common in  cases  of  chronic  cholecystitis  to  find  the  gall  bladder  filled  with 
black,  thick,  sandy  bile. 

The  diagnosis  depends  upon  the  various  gastric  disturbances  enumerated 
above,  together  with  the  dull  aching  or  burning  pain  in  the  right  hypochon- 
drium, and  the  finding  of  an  area  of  tenderness  in  the  region  of  the  gall  bladder. 
This  tenderness  is  practically  always  present  and  can  be  elicited  by  placing 
the  finger-tips  underneath  the  costal  arch,  and  when  the  abdominal  muscles 
are  relaxed,  have  the  patient  take  a  deep,  full  inspiration  forcing  the  gall 
bladder  against  the  finger-tips. 

STONES  IN  THE  COMMON  DUCT 

History.  With  stones  in  the  common  duct  it  is  not  uncommon  to  find  a 
history  of  frequent  attacks  of  pain  which  have  occurred  at  variable  intervals 
for  years,  accompanied  by  a  slight  jaundice.  Suddenly  there  will  be  an  attack 
of  severe  pain  with  a  rapid  and  pronounced  jaundice.  This  is  the  time  at 
which  the  stone  passes  into  the  common  duct.  If  the  stone  be  a  small  one 
it  may  pass  on  into  the  intestine  and  the  jaundice  entirely  clear  up  in  a  few 
days.  If  the  stone  becomes  impacted  in  the  common  duct  there  will  be  a  com- 
plete obstruction  to  the  passage  of  bile,  resulting  in  severe  jaundice  and  en- 
largement of  the  liver. 

It  is  rare  to  meet  with  an  acute,  permanent  occlusion  of  the  common  duct 
from  stone.  As  soon  as  the  stone  becomes  impacted,  the  presence  of  the  bile 
causes  a  dilatation  of  the  duct  so  that  a  stone  Avhich  at  first  fits  tightly  will 
be  loose  in  the  duct,  allowing  the  bile  to  pass  around  it.  AVe  then  have  a 
condition,  which  Fenger  described,  of  the  stone  acting  as  a  "ball-valve"  in 
the  duct,  which  then  gives  a  characteristic  history  of  chronic  common  duct 
stone ;  frequent  attacks  of  pain  occurring  once  or  twice  a  week,  accompanied 
by  slight  rigor  and  temperature  of  101°,  with  or  without  noticeable  jaundice. 


510  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

In  practically  all  of  these  cases  close  inspection  will  reveal  the  presence  of 
slight  icterus. 

In  many  patients  with  an  obstruction  of  the  common  duct  there  is  a  con- 
siderable loss  in  weight.  It  is  important  to  bear  this  point  in  mind,  as  a 
symptom  of  stone  in  the  common  duct.  The  rapid  loss  of  weight  is  very 
apt  to  suggest  a  diagnosis  of  malignant  disease. 

The  jaundice  of  malignant  disease  is  not  accompanied  b}'  pain,  it  steadily 
increases  and  does  not  vary  from  day  to  day,  as  it  usually  does  in  common 
duct  stones.  When  the  jaundice  is  due  to  some  pressure  from  outside  the 
duct,  as  a  carcinoma  of  the  head  of  the  pancreas,  the  gall  bladder  will  be  dis- 
tended, while  in  cases  where  the  obstruction  is  from  a  stone  within  the  duct 
the  gall  bladder  is  usually  contracted. 

Indications  for  operation.  So  long  as  the  gall  stones  simply  remain  in  the 
gall  bladder  without  causing  any  complications,  the  harm  to  the  patient  is 
relatively  slight.  The  patient's  comfort  will  be  greatly  disturbed  on  account 
of  the  disturbances  of  digestion.  The  pain  will  not  be  extreme  and  he  usually 
accumulates  an  abundance  of  fat,  especially  in  the  abdominal  walls.  It  has 
consequently  been  held  by  many  authorities  that  it  is  not  wise  to  make  use  of 
radical  measures  for  the  removal  of  gall  stones  so  long  as  they  do  not  give 
rise  to  any  grave  disturbances.  This  undoubtedly  would  be  a  proper  and 
reasonable  view  to  take  were  the  danger  to  the  patient  approximately  the 
same  before  and  after  the  occurrence  of  these  complications.  This,  however, 
is  not  the  case.  Experience  has  shown  us  that  the  mortality  in  cases  which 
are  operated  before  any  serious  complications  arise  is  practically  nil,  while 
the  deaths  that  happen  in  the  complicated  cases  undoubtedly  might  have  been 
saved  had  the  operation  been  performed  before  these  complications  arose. 

It  was  the  mortality  and  complications  of  delay  that  placed  the  early  and 
interval  operation  for  appendicitis  on  a  sound  surgical  footing.  To  remove  the 
disease  while  still  in  the  appendix  and  avoid  the  various  complications  was  a 
logical  conclusion.  The  same  reason  applies  with  equal  force  to  the  early 
operation  for  gall  stone  disease.  Remove  the  disease  while  still  in  the  gall 
bladder. 

Complications  and  sequelae.  The  complications  which  are  likely  to  be 
caused  by  the  presence  of  gall  stones  may  be  chronic  in  character,  taking  the 
form  of  digestive  disturbances  and  giving  rise  to  almost  constant  discomfort. 
This  is  probabl}^  due  to  the  interference  of  the  passage  of  food  through  the 
pylorus  into  the  duodenum,  causing  dilatation  of  the  stomach. 

Again,  the  patient  may  be  in  a  slightly  septic  condition,  because  there  is 
more  or  less  absorption  of  the  septic  material  from  the  infected  residual  bile, 
as  well  as  from  the  products  of  fermentatio2i  in  the  dilated  stomach.  These 
conditions  frequently  result  in  chronic  invalidism,  making  it  impossible  for 
the  patient  to  follow  ordinary  occupations  and  to  enjoy  life  in  any  way.  The 
constant  irritation  of  the  gall  bladder,  due  to  the  pressure  of  the  gall  stones, 
undoubtedly  has  much  to  do  with  the  development  of  carcinoma  in  this  organ. 

In  eases  of  primary  carcinoma  of  the  gall  bladder,  we  have  always  been 
able  to  get  a  history  of  gall  stones  dating  back  man,v  years,  and  have  invari- 
ably found  these  present  in  the  gall  bladder  in  such  instances  at  the  time  of 
the  operation  or  autopsy.  Aside  from  these  chronic  affections  gall  stones  may 
at  any  time  cause  exceedingly  grave  acute  conditions. 

These  complications  are  all  the  result  of  inflammation  and  the  sequelfe 
must  consequently  depend  upon  the  extent  to  which  this  develops. 

We  take  the  following  list  of  complications  from  Mayo  Robson's  excellent 
article  on  this  subject,  because  its  arrangement  is  most  satisfactory: 

1.    Ileus  due  to  paresis  of  the  bowel,  leading  to  enormous  distension  of 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER  511 

the  abdomen  and  to  symptoms  and  appearances  of  acute  intestinal  obstruc- 
tion, apparently  the  consequence  of  the  violent  pain. 

2.  Acute  intestinal  obstruction  dependent  on 

(a)  Paralysis  of  gut  due  to  local  peritonitis  in  the  neighborhood  of 
the  gall  bladder. 

(b)  Volvulus  of  small  intestine. 

(c)  Stricture  of  intestine  by  adventitious  bands,  originally  produced 
as  a  result  of  gall  stones. 

(d)  Impaction  of  a  large   gall  stone  in  some  part  of  the  intestine 
after  ulcerating  its  way  from  the  bile  channels  into  the  bowels. 

3.  General  hemorrhage,  the  result  of  long-continued  jaundice,  dependent 
either  on  gall  stones  alone,  or  on  cholelithiasis  associated  with  malignant 
disease  or  with  interstitial  pancreatitis. 

4.  Localized  peritonitis,  producing  adhesions  which  may  then  become  a 
source  of  pain  even  after  the  gall  stones  have  been  gotten  rid  of.  It  is  believed 
that  nearly  every  serious  attack  of  biliary  colic  is  accompanied  by  adhesive 
peritonitis,  as  experience  shows  that  adhesions  are  found  practically  in  all 
cases  where  there  have  been  characteristic  seizures. 

5.  Dilatation  of  stomach  depending  upon  adhesions  around  the  pylorus, 

6.  Ulceration  of  the  bile  passages,  establishing  a  fistula  between  them 
and  the  intestine. 

7.  Stricture  of  the  cystic  or  common  duct. 

8.  Abscess  of  the  liver. 

9.  Localized  peritoneal  abscess. 

10.  Abscess  in  the  abdominal  wall. 

11.  Fistula  at  the  umbilicus,  or  elsewhere  on  the  surface  of  the  abdomen, 
discharging  mucus,  muco-pus,  or  bile. 

12.  Empyema  of  the  gall  bladder. 

13.  Infective  and  suppurative  cholangitis. 

14.  Septicemia  or  pyemia. 

15.  Phlegmonous  cholecystitis. 

16.  Gangrene  of  the  gall  bladder. 

17.  Perforative  peritonitis  due  to  ulceration  through  or  to  rupture  of 
the  gall  bladder  or  ducts,  leading  to  extravasation  of  infected  bile  into  the 
general  peritoneal  cavity. 

18.  Pyelitis  on  the  right  side  due  to  a  gall  stone  ulcerating  or  an  abscess 
of  the  gall  bladder  bursting  into  the  pelvis  of  the  kidney, 

19.  Cancer  of  the  gall  bladder  or  ducts. 

20.  Subphrenic  abscess. 

21.  Pleurisy  or  empyema  of  the  right  pleura. 

22.  Pneumonia  of  lower  lobe  of  right  lung. 

23.  Chronic  invalidism  or  inabilitj^  to  perform  any  of  the  ordinary  busi- 
ness or  social  duties  of  life, 

24.  Gangrenous  or  suppurative  pancreatitis, 

25.  Chronic  interstitial   pancreatitis. 

26.  Infective  endocarditis. 

27.  Cirrhosis  of  liver. 

28.  Appendicitis  due  to  extension  of  inflammation  from  the  gall  bladder 
or  to  impaction  of  a  gall  stone  in  the  appendix. 

Contraindications  to  operation.  In  disease  of  the  gall  bladder  there  are 
some  definite  contraindications  to  operation  which,  it  is  believed,  have  now 
been  quite  thoroughly  established  by  clinical  observation. 

1.  It  is  ordinarily  unwise  to  operate  during  the  attack  of  gall  stone  colic. 

2.  Severe  icterus  is  a  contraindication  to  a  prolonged  operation. 

3.  The  same  is  true  of  prostration  following  long-continued  suffering. 


512  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

4.  Cases  complicated  with  carcinoma  belong  to  the  same  class. 

5.  Patients  with  ecchymotic  spots  are  almost  certain  to  die  if  operated. 
In  all  these  cases  if  an  operation  must  be  performed  it  should  be  limited 

to  drainage  of  the  gall  bladder  and  removal  of  the  stones  in  this  viscus,  and 
all  further  manipulations  should  be  postponed  until  the  patient  is  in  a  better 
general  condition. 

Treatment.  Gall  stones  and  severe  infections  of  the  bile  tracts  have  come 
to  be  looked  upon  as  purely  surgical  affections.  However,  it  has  been  our 
experience  that  cases  with  acute  exacerbations  fare  better  if  the  operation  is 
deferred  until  the  acute  symptoms  have  subsided.  In  any  case  complicated 
with  an  acute  inflammatory  condition,  we  believe  that  the  same  general  prin- 
ciple should  be  employed  in  the  treatment  of  this  condition  as  inflammatory 
processes  involving  the  peritoneum  from  any  other  cause.  So  long  as. there 
is  no  circumscribed  accumulation  of  pus,  the  treatment  must  consist  in  rest. 
This  can  be  secured  most  readily  by  using  gastric  lavage  in  order  to  remove 
remnants  of  food  or  decomposing  mucus  from  the  stomach,  then  prohibiting 
the  use  of  cathartics  and  of  food  by  mouth. 

We  desire  especially  to  emphasize  the  value  of  securing  absolute  rest  of 
the  stomach  by  the  use  of  gastric  lavage,  and  then  not  placing  any  form  of 
nourishment  in  the  stomach  but  confining  the  patient  to  exclusive  rectal 
alimentation,  in  the  treatment  of  patients  suffering  from  acute  cholecystitis 
characterized  by  the  presence  of  severe  gall  stone  colic.  AVe  have  seen  many 
cases  where  the  pain  was  excruciating  and  large  doses  of  morphine  given 
hypodermically  failed  to  give  relief,  in  whom  the  pain  disappeared  almost 
completely  without  further  opiates  after  the  use  of  gastric  lavage.  In  these 
cases  the  pain  does  not  recur  unless  some  form  of  nourishment  is  given  by 
mouth ;  even  water  often  causes  recurrence  of  pain. 

It  may  be  difficult  to  explain  this  observation,  but  it  is  likely  that  even 
a  small  amount  of  food  or  mucus  in  the  stomach  will  be  forced  into  the 
duodenum  and  that  when  it  passes  over  the  entrance  of  the  common  duct,  it 
causes  a  contraction  of  the  gall  bladder  and  this  excites  the  pain. 

The  use  of  moist  heat  in  the  form  of  poultices  or  fomentations,  or  of  cold 
by  means  of  an  ice  bag,  give  the  patient  great  comfort  and  appear  undoubtedly 
beneficial. 

Morphia  may  be  given  hypodermically  if  necessary,  but  so  long  as  neither 
food  nor  cathartics  are  given  by  mouth  the  pain  usually  subsides  rapidly  and 
permanently.  Nourishment  may  be  supplied  by  enema  not  oftener  than  once 
in  four  hours,  nor  in  larger  quantities  than  four  ounces  at  a  time.  We  prefer 
for  this  purpose  one  of  the  various  reliable  predigested  foods  mixed  with 
three  ounces  of  warm  normal  salt  solution.  In  many  cases  we  give  no  nourish- 
ment solution  at  all,  and  instead  give  continuous  salt  solution  per  rectum  by 
the  drop  method.  Unless  the  acute  condition  is  complicated  by  a  mechanical 
obstruction  of  the  intestines,  the  patient's  chance  for  recovery  from  the  acute 
attack  is  far  better  without  than  with  an  operation. 

It  is  necessary  to  make  a  definite  distinction  between  intestinal  obstruc- 
tion due  to  peritonitis  and  that  due  to  a  mechanical  condition,  such  as  the 
impaction  of  a  gall  stone.  The  former  is  so  much  more  common  than  the 
latter  that  it  is  only  very  seldom  the  latter  need  be  considered.  Mechanical 
obstruction  due  to  impaction  of  a  gall  stone  is  characterized  by  the  sudden 
onset  of  symptoms  of  an  acute  intestinal  obstruction,  without  the  inflamma- 
tory symptoms  which  must  be  present  if  it  was  due  to  a  peritonitis. 

When  the  patient  has  recovered  from  his  acute  attack  the  further  treat- 
ment may  be  conducted  medically,  which  will  not  cure  but  may  improve  his 
condition  very  greatly,  or  surgically  which  is  likely  to  result  in  a  perfect 
permanent  recovery. 


SUKGERY  OF  THE  GALL  BLADDER  AND  LIYER  513 

Medical  treatment.  The  medical  treatment  must  consist  cliiefly  in  the  use 
of  large  quantities  of  water,  preferably  taken  hot,  and  in  the  use  of  a  diet 
fairly  free  from  sugar  and  starch. 

We  believe,  however,  that  the  greatest  benefit  comes  from  drinking  a 
great  amount  of  good  "vvater  and  never  eating  quite  enough  to  satisfy  the 
hunger,  and  from  taking  vigorous  out-of-door  exercise,  such  as  horseback 
riding,  walking  or  rowing.  Sodium  phosphate  in  doses  of  one  drachm  or 
more,  in  a  large  goblet  of  hot  water,  half  an  hour  before  each  meal,  and  pure 
olive  oil  in  doses  of  one-half  to  four  ounces,  at  bed  time,  seems  to  have  given 
relief  to  patients  suffering  from  gall  stones,  many  of  them  rem.aining  free  from 
severe  attacks  for  a  long  period  of  time  by  combining  these  remedies  with 
proper  diet  and  exercise. 

Whether  the  relief  is  due  to  the  fact  that  in  this  manner  constipation  is 
prevented  and  elimination  facilitated  hy  the  large  draughts  of  hot  water,  or 
whether  there  is  some  special  virtue  in  the  remedies,  it  is  difficult  to  say.  That 
many  of  the  patients  are  relieved  of  tlieir  gall  stone  colics  upon  following 
this  plan  of  treatment,  there  can  be  no  doubt. 

It  is  plain,  however,  that  this  form  of  treatment  can  be  of  benefit  only  to 
a  limited  number  of  patients,  namely,  those  in  whom  there  is  no  impaction  of 
the  gall  stones  in  the  gall  badder,  or  in  the  common  or  cystic  duct,  and  which 
are  not  complicated  by  serious  lesions  of  any  portion  of  the  mucous  membrane 
lining  these  parts,  or  with  extensive  adhesions.  Moreover,  these  patients  are 
apt  to  have  recurrences  Avith  one  or  m.ore  of  the  complications  enumerated 
above.  Aside  from,  this  there  is  always  the  danger  of  the  development  of 
carcinoma  as  a  result  of  the  long-continued  irritation. 

Of  late  it  has  been  our  practice  to  advise  the  removal  of  stones  in  all  cases, 
provided  the  patient's  general  condition  would  warrant  such  an  operation, 
and  to  carry  out  the  palliative  measures  as  described  above  only  in  cases  that 
refused  operation. 

Surgical  technique.  In  operations  on  the  gall  bladder  and  especially  those 
upon  the  bile  ducts,  considerable  advantage  may  be  gained  by  placing  a  sand 
bag  at  or  under  the  patient's  back  at  or  a  little  above  the  level  of  the  liver. 
This  will  cause  the  liver  to  present  in  the  woimd  and  afford  easy  access  to  the 
cystic  and  common  ducts. 

For  all  gall  bladder  operations,  a  straight  incision  made  through  the  right 
rectus  muscle,  near  its  outer  border,  is  undoubtedly  the  best,  primarily.  The 
upper  end  of  the  incision  starts  at  the  costal  margin  and  extends  downward. 
The  incision  is  first  carried  through  the  skin,  superficial  and  deep  fascia  down 
to  the  muscle  fibres. 

These  should  be  separated  longitudinally,  by  means  of  a  blunt  instrument 
like  the  handle  of  a  scalpel,  so  that  none  of  the  fibres  shall  be  cut.  The  incision 
is  completed  by  carrying  it  through  the  transversalis  fascia  and  the  peritoneum. 
The  wound  should  be  long  enough  to  admit  the  entire  hand,  as  advised  by 
Maurice  Richardson.  This  is  important  because  the  next  step  must  consist 
in  a  careful  palpation  of  the  gall  bladder,  the  cystic,  the  hepatic  and  the 
common  ducts.  This  cannot  be  done  thoroughly  without  introducing  the 
entire  hand. 

The  pancreas,  duodenum  and  the  pylorus  shotild  be  examined  at  the  same 
time. 

The  various  incisions  used  in  operations  upon  the  gall  tract  are  illustrated 
in  previous  plates. 

Should  it  be  found  that  more  room  is  needed  than  the  rectus  incision  gives, 
it  may  be  obtained  by  carrying  the  upper  end  of  the  incision  upwards  and 
inwards,  cutting  the  rectus  fibres  about  one  inch  from  the  costal  margin,  which 
virtually  converts  our  primarv  rectus  incision  into  one  first  suggested  bv  Mavo 

33  cc  >  . 


514  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

Robson.  Or  this  rectus  incision  may  be  converted  into  the  "S"  shaped  incision, 
as  devised  by  Bevan.  It  is  rare  though  that  there  will  be  need  for  any  other 
than  the  straight  rectus  opening. 

CHOLECYSTOTOMY 

Cholecystotomy  is  the  operation  of  choice  for  removal  of  stones  from  the 
gall  bladder. 

Cholecystotomy  is  further  performed  for  the  purpose  of  establishing  drain- 
age of  the  gall  bladder,  which  is  useful  in  not  only  relieving  irritation  of  the 
gall  bladder  and  biliarj^  ducts,  but  indirectly  it  seems  to  drain  the  liver  and 
the  pancreas  and  as  a  result  of  this  drainage  these  organs,  when  generally  en- 
larged as  a  result  of  chronic  inflammation  or  irritation  due  to  faulty  drainage, 
will  decrease  in  size  very  rapidly. 

It  is  consequently  important  to  determine  these  conditions  before  deciding 
upon  the  operation  to  be  chosen  in  any  given  case.  After  making  the  incision, 
the  hand  is  introduced  into  the  abdominal  cavity  and  the  gall  bladder  is 
palpated  between  the  finger  and  thumb.  It  is  then  followed  downwards  and 
inwards  and  the  cystic,  hepatic  and  common  ducts  are  palpated  in  succession. 

Occasionally  the  gall  bladder  may  be  so  tense  that  nothing  can  be  de- 
termined concerning  the  character  of  its  contents,  except  that  whatever  the 
gall  bladder  may  contain  it  is  impossible  for  this  substance  to  pass  on  freely 
into  the  duodenum,  and  this,  in  itself,  is  the  strongest  indication  for  a 
cholecystotomy.  If  this  condition  is  found,  or  if  gall  stones  are  discovered  in 
the  gall  bladder  or  the  cystic  duct,  but  none  in  the  hepatic  or  common  ducts, 
this  operation  is  plainly'  indicated. 

The  examination  may  have  revealed  more  or  less  extensive  recent  or  old 
adhesions  between  the  gall  bladder  and  the  surrounding  organs. 

These  adhesions  may  include  the  liver,  the  omentum,  the  transverse  colon, 
the  duodenum,  or  the  stomach  and  in  some  instances  even  the  right  kidney, 
or  they  may  include  any  two  or  more  of  these  organs. 

If  they  are  recent,  or  if  they  distort  one  or  more  of  these  organs,  it  is 
well  to  loosen  or  ligate  and  cut  these  adhesions.  If  they  have  existed  for  a 
long  period  of  time  without  apparently  doing  any  harm,  it  is  better  to  leave 
them  undisturbed.  It  must,  however,  be  borne  in  mind  that  undoubtedly  the 
adhesions  of  the  gall  bladder  frequently  draw  this  down  and  cause  it  to  be- 
come sacculated  so  that  it  will  contain  residual  bile,  which  in  turn  favors 
infection  of  this  fluid,  and  thus  the  formation  of  gall  stones.  It  is  consequently 
important  to  remove  any  adhesions  which  seem  to  show  a  tendency  to  cause 
sacculation  of  the  gall  bladder. 

This  having  been  accomplished,  soft  gauze  pads  moistened  with  warm 
normal  salt  solution  are  placed  about  the  gall  bladder  after  the  latter  has 
been  grasped  at  its  most  prominent  point  with  one  or  two  pairs  of  forceps. 

This  act  of  packing  away  the  remaining  portion  of  the  peritoneal  cavity 
should  be  done  with  the  greatest  care,  to  prevent  soiling  during  the  following 
steps  of  the  operation. 

A  trocar  is  then  plunged  into  the  gall  bladder  to  drain  away  the  bile,  pus 
or  mucus,  as  the  case  may  be,  contained  in  the  cavity.  The  trocar  devised  by 
Dr.  E.  H.  Ochsner  is  undoubtedly  most  convenient,  because  with  it  the  gall 
bladder  can  be  emptied  perfectly  without  the  slightest  damage  or  soiling  any 
of  the  surrounding  tissues. 

Should  the  gall  bladder  be  contracted  because  of  the  long-continued  de- 
structive inflammation,  which  distinguishes  old  gall  stone  cases  from  obstruc- 
tion due  to  malignant  growths,  according  to  the  law  of  Courvoiser,  it  might 
not  be  necessary  to  make  use  of  the  trocar,  because  there  will  be  no  bile  in 


4 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


515 


what  is  left  of  the  gall  bladder.    In  these  cases  the  most  prominent  portion  of 
the  gall  bladder  is  grasped  by  the  forceps  and  an  incision  made  through  the 


Incisions  for  Gall  Bladder  and  Gall  DrcT  Operations. 

1.  Eight  rectus  incision  with  extension  at  upper  end,  according  to  plan  of  Mayo  Eobson. 

2.  Eight  rectus  incision  with  upper  and  lower  extension,  according  to  plan  of^Bevan. 

3.  Oblique  incision  along  border  of  ribs. 

highest  part,  which  is  also  the  next  step  after  the  fluid  has  been  aspirated  in 
the  other  class  of  cases. 

If  there  is  still  a  little  fluid  present,  this  is  absorbed  by  lightly  tamponing 


516  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

the  cavity  of  the  gall  bladder  with  a  narrow  strip  of  aseptic  gauze  and  with- 
drawing it.  This  can  be  repeated  a  number  of  times.  A  blunt  gall  stone  scoop 
is  now  introduced  and  gently  withdrawn,  bringing  out  as  many  of  the  stones 
as  can  be  reached  in  this  manner.  Then,  while  the  assistant  holds  up  the  gall 
bladder  with  hemostatic  forceps  attached  to  the  edge  of  the  wound,  the 
surgeon's  hand  is  again  introduced  into  the  abdominal  cavity,  and  the  gall 
bladder  and  all  its  ducts  are  once  more  carefully  palpated. 

If  stones  are  still  present,  these  can  be  removed  with  the  scoop,  guided  by 
the  hand  in  the  abdominal  cavity.  If  there  are  stones  in  the  cystic  duct,  these 
can  frequently  be  forced  back  into  the  gall  bladder  by  a  gentle  "milking" 
motion  betAveen  the  forefinger  and  thumb.  Occasionally  this  can  be  aided  by 
the  use  of  a  small  curette  guided  by  the  other  hand. 

In  a  few  instances  it  has  been  possible  to  transfer  to  the  gall  bladder  not 
onlj'  stones  in  the  cystic  duct  but  even  those  in  the  common  and  hepatic  duct. 
Great  caution  must,  however,  be  practised,  because  less  injury  is  done  to  the 
patient  by  making  an  incision  into  these  ducts  than  by  severe  manipulation  in 
the  attempt  at  removing  stones,  especially  if  these  are  immovable  as  the  result 
of  impaction. 

So  far,  the  steps  of  the  operation  are  agreed  upon  practically  by  every  one 
who  has  had  a  large  experience  in  the  treatment  of  these  cases.  But  from 
this  point  on,  authorities  of  equal  ability  vary  in  details  of  their  technique. 

Varying  methods.  We  have  used,  at  various  times,  most  of  the  methods 
that  have  been  recommended,  thinking  one  might  be  indicated  under  certain 
conditions,  while  another  might  be  more  suitable  for  a  slightly  different  case, 
but  we  are  convinced  that  the  special  benefits  from  these  various  operations 
are  entirely  imaginary,  and  that  this  is  simply  a  remnant  of  the  pedantry 
which  has  been  so  uniformly  a  part  of  our  professional  work  for  centuries. 

A  proven  simple  technique.  In  over  two  thousand  successive  cases  we 
have  employed  the  following  simple  technique,  after  being  satisfied  that  all 
the  stones  had  been  removed. 

1.  The  gall  bladder  is  carefully,  but  gently  and  loosely,  tamponed  with 
a  long  strip  of  dry  gauze.  This  serves  to  prevent  hemorrhage  from  the  mucous 
lining  of  the  gall  bladder,  which  is  frequently  severely  congested  and  often 
covered  with  bleeding  granulations. 

2.  The  transversalis  fascia  and  the  peritoneum  of  the  upper  angle  of  the 
wound  is  then  sutured  to  the  edge  of  the  gall  bladder,  one  to  two  cm.  back 
from  the  edge  of  the  opening.  The  accompanying  plate  shows  the  gall  bladder 
with  the  forceps  upon  its  edge  and  drawn  out  through  the  wound,  and  a  cat- 
gut stitch  being  placed  which  attaches  the  gall  bladder  to  the  peritoneum. 
The  stitch  in  the  gall  bladder  passes  doM'n  to,  but  not  through,  the  mucous 
lining  of  the  gall  bladder. 

If  the  gall  bladder  is  small  and  shrunken  the  peritoneum  and  transversalis 
are  brought  down  to  it  at  one  or  two  points  and  a  piece  of  gauze  is  carried 
down  to  the  gall  bladder,  and  between  the  gauze  and  the  surrounding  tissue 
a  piece  of  rubber  tissue  is  placed.  Attaching  the  gall  bladder  in  this  manner 
facilitates  drainage,  and  prevents  the  gall  bladder,  later  on,  from  becoming 
sacculated. 

3.  The  abdominal  wall  is  now  closed  as  illustrated  in  the  plate.  Two  of 
the  fine  silk-worm  gut  stitches  are  passed  through  all  the  tissues  down  to, 
but  not  through,  the  transversalis  fascia;  these  are  left  untied  until  the  fol- 
lowing rows  of  catgut  sutures  have  been  applied  in  order  to  prevent  the 
formation  of  a  ventral  hernia,  by  carefully  approximating  the  following  lay- 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


517 


ers ;  a,  peritoneum  and  transversalis  fascia ;  b,  rectus  abdominis  muscle,  apo- 
neurosis of  the  external  and  the  outer  layer  of  the  internal  oblique  muscle 
passing  in  front  of  the  rectus  abdominis  muscle  at  this  point ;  d,  the  skin. 

These  layers  are  all  approximated  by  suturing  with  unchromicized  cat-gut, 


A,  B,  Trocar  for  aspirating  the  fluid  from  the  gall  bladder.  C,  Double  scoop  for  remov- 
ing gall  stones.  D,  Forceps  for  removing  gall  stones.  E,  Eubber  tube  used  for  the  hepatic 
or  the  common  duct. 


except  the  skin,  for  which  horse-hair  is  used.     Now  by  tying  the  silk-worm 
gut  sutures  the  closure  of  the  wound  is  completed. 

4.  Some  rubber  tissue  is  now  stuffed  down  to  the  gall  bladder,  between 
the  edges  of  the  abdominal  wall  and  the  gauze  tampon,  to  facilitate  the  re- 
moval, about  the  fifth  day,  when  the  rubber  drainage  tube  is  inserted  in  the 
gall  bladder  in  its  place. 


518 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


Other  methods.  The  other  methods  which  seem  equall}^  satisfactory  con- 
sist in  substituting  for  the  gauze  tampon  in  the  gall  bladder,  a  simple  rubber 
tube,  or  a  split  rubber  tube  filled  with  a  strip  of  gauze  or  a  cigarette  drain. 
Any  one  of  these  may  be  fastened  in  the  gall  bladder  by  placing  a  purse- 
string  suture  around  the  opening,  inverting  the  edges,  and  then  drawing  the 
purse-string  just  sufficiently  tight  to  prevent  leakage. 


Cholecystotomy. 

Till?  wound  is  held  open  by  means  of  sharp  retractors.  The  gall  bladder  is  drawn  out 
of  the  altdominal  wound  by  means  of  hemostatic  forceps;  one  suture  is  in  place  attaching 
the  gall  liladder  to  the  peritoneum  and  transversalis  fascia,  and  a  second  suture  is  being 
applied.  The  umbilicus  should  be  opposite  the  lower  end  of  the  incision,  instead  of  being 
opposite  its  center. 

This  incision  should  be  three  inches  nearer  the  costal  arch.  It  is  well  to  insert  the  suture 
on  the  side  of  the  gall  bladder  transversely  in  order  to  grasp  and  compress  the  branches  of 
the  cystic  artery  more  perfectly.  Omitting  this  precaution  may  occasionally  result  in  severe 
hemorrhage. 


Still  another  method  consists  in  applying  one  of  these  various  forms 
of  drainage,  and  then  simply  permitting  this  to  project  from  the  upper 
angle  of  the  abdominal  wound  without  suturing  the  gall  bladder  to  the  parietal 
peritoneum.  Personally,  we  have  never  been  favorably  impressed  by  this 
course. 

In  case  it  seems  wise  to  continue  the  drainage  of  the  gall  bladder  for  a 
considerable  period,  the  patient  can  be  made  more  comfortable  by  inserting 
a  Jacob's  retention  catheter  of  proper  size  into  the  gall  bladder,  placing  a 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER  519 

glass  tube  in  the  distal  end  of  this  catheter  and  tying  a  soft  rubber  bag  to  this 
in  order  to  collect  the  bile.  (See  plate.)  Whenever  it  seems  the  proper  time 
to  interrupt  this  drainage,  the  opening  will  close  spontaneously  upon  with- 
drawing the  catheter. 

For  a  time  we  substituted  a  rubber  drainage  tube  for  the  gauze  packing 
in  these  cases,  but  this  was  followed  in  a  large  proportion  of  cases  by  unsatis- 
factory results.  It  seemed  that  while  the  gauze  packing  had  caused  the  more 
or  less  pathological  mucous  membrane  lining  of  the  gall  bladder  to  change  to 
a  normal  condition,  the  presence  of  a  rubber  drainage  tube  seemed  to  increase 
the  pathological  condition  of  the  mucous  lining  and  we  found  it  necessary  to 
remove  quite  a  proportion  of  the  gall  bladders  which  had  been  drained  by 
means  of  a  drainage  tube.  We  also  found  that  in  inserting  the  drainage  tube 
into  the  gall  bladder  after  removing  the  gauze  packing  about  the  fifth  day, 
a  similar  effect  resulted  in  some  cases,  and  that  the  late  results  in  those  cases 
in  which  no  further  attempt  was  made  for  drainage  except  by  the  use  of  a 
Jacob's  catheter,  were  very  much  more  satisfactory. 

We  also  found  that  gall  bladders  that  were  not  sutured  to  the  peritoneum 
and  transversalis  fascia  were  more  likely  to  give  trouble  following  the  opera- 
tion than  those  in  which  this  step  was  made  use  of  in  the  operation. 

CHOLECYSTECTOMY 

This  operation  seems  indicated  in  cases  in  which  there  is  a  permanent 
obstruction  of  the  cystic  duct,  which  is  usually  due  to  a  cicatricial  contraction 
of  an  ulcer,  most  commonly  caused  by  the  impaction  of  a  stone. 

It  may  also  be  due  to  the  formation  of  a  valve  in  the  neck  of  the  gall  blad- 
der at  its  entrance  into  the  cystic  duct.  Occasionally  such  a  valve  will  permit 
the  free  flow  of  bile  into  the  gall  bladder,  but  will  not  in  the  opposite  direc- 
tion. The  gall  bladder  should  also  be  removed  in  cases  in  which  its  walls  are 
so  thin  that  it  will  not  be  able  to  act  as  a  contractile  organ. 

Cholecystectomy  should  be  performed  in  early  cases  of  primary  carcinoma 
of  the  gall  bladder.  In  all  cases  in  which  the  gall  bladder  has  been  badly 
diseased  for  some  time,  the  disease  being  limited  to  the  organ  alone,  and  cir- 
cumstances permit  of  easy  removal,  cholecystectomy  will  be  the  operation  of 
choice. 

The  removal  of  the  gall  bladder  is  usually  not  a  difficult  matter  if  it  is 
approached  from  the  right  direction.  The  following  simple  steps  should  be 
followed : 

1.  The  same  incision  as  in  cholecystotomy  should  be  made.  Occasionally 
if  there  are  many  adhesions,  so  that  it  is  difficult  to  reach  the  lower  end  of 
the  gall  bladder,  the  incision  may  be  lengthened,  according  to  the  plan  advised 
by  Bevan,  by  extending  the  upper  end  of  the  incision  inward  and  the  lower 
end  outward;  or  it  may  be  extended  according  to  Mayo  Robson,  between  the 
edge  of  the  costal  cartilages  and  the  lower  end  of  the  sternum,  in  order  that 
the  liver  with  the  gall  bladder  may  be  inverted  in  an  upward  direction. 

2.  Two  pair  of  hemostatic  forceps  are  then  applied,  one  directly  to  the 
cystic  duct,  grasping  at  the  same  time  the  cystic  artery  which  supplies  the 
gall  bladder;  the  second  pair  is  applied  to  the  neck  of  the  gall  bladder  at  a 
distance  of  one  cm.  from  the  other.  The  plate  shows  the  two  pair  of  forceps 
in  place.  The  gall  bladder  is  now  cut  loose  just  beyond  the  second  forceps 
and  between  this  and  the  first  pair,  as  shown  in  the  next  plate. 

3.  An  incision  is  now  made  along  the  sides  of  the  gall  bladder,  through 
its  peritoneal  covering,  about  one  cm.  from  its  attachment  to  the  liver,  and 
then  the  organ  can  be  enucleated  without  difficulty. 

If  there  is  any  considerable  amount  of  hemorrhage  from  the  surface,  a 


520 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


O^ 


Eetention  Tube,  After  the  Plan  of  Jacob  's  Eetention  Catheter. 

a  shows  the  bulb-like  end  in  the  position  it  takes  when  in  place,  h  shows  the  end  stretched 
over  a  j)robe  c  in  order  to  reduce  its  size  during  its  introduction.  To  be  used  in  draining 
cavities  like  the  urinary  bladder,  gall  bladder,  hydronephrotic  kidney,  etc.  This  tube  is  also 
used  as  a  permanent  feeding  tube  in  gastrostomy. 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


521 


hot  tampon  of  gauze  against  the  surface  for  a  few  minutes  will  control  the 
oozing  at  once,  and  then  the  raw  surface  can  be  closed  by  suturing  the  two 
peritoneal  folds  with  catgut  as  shown  in  the  plate. 

The  next  plate  (a)  shows  the  cutting  of  the  peritoneal  fold  between  the 
gall  bladder  and  the  liver;  (b)  where  the  gall  bladder  and  the  cystic  duct  have 


■7%, 


/^ 

1 

, 

■  1 

t 

1 
1 

Removal  of  Stone  from  Common  Duct  and  Drainage  of  Common  Duct. 

Sutures  of  fine  cat-gut  are  applied  to  each  side  of  the  proposed  incision.  These  are 
utilized  later  to  hold  in  place  a  rubber  drainage  tube  which  is  inserted  in  the  incision  in  the 
common  duct,  and  also  for  fastening  a  piece  of  gauze  which  is  packed  around  the  tube  to 
further  protect  the  general  peritoneal  cavity  against  contamination. 

(Taken  from  Dr.  W.  J.  Mayo's  original  drawings.) 


been  removed.  Then  following  (a)  where  the  two  edges  of  the  peritoneum 
have  been  sutured  covering  over  the  raw  surface  made  by  excising  the  gall 
bladder;  and  (b)  shows  rubber  drain  placed  in  hepatic  duct  which  is  pulled 
downwards  for  sake  of  illustration. 

4.    Disposition  of  the  stump.     If  drainage  is  not  desired,  a  ligature  can 
be  placed  about  the  stump  of  the  cystic  duct,  including  the  cystic  artery. 


522  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

If  it  is  doubtful,  the  artery  forceps  may  be  left  in  place,  and  may  be  sur- 
rounded by  gauze  and  rubber  protective,  and  permitted  to  pass  out  of  the 
upper  angle  of  the  wound.  This  may  be  loosened  after  thirty-six  hours,  or 
sooner,  if  it  should  become  apparent  that  drainage  is  desired. 

It  is  well  in  these  cases  to  insert  a  drainage  tube  to  a  point  just  below  the 
stump  for  the  purpose  of  providing  for  an  emergency.  It  is  immaterial  what 
form  of  drainage  tube  is  chosen.  In  case  drainage  of  the  cystic  duct  is  de- 
sired, the  cystic  artery  is  caught  separately  at  the  end  of  the  stump  and  ligated 
and  a  small  rubber  drainage  tube  is  introduced  directly  into  the  common  duct 
through  the  cystic  duct. 

The  figure  (e)  shows  a  drainage  tube  which  is  most  useful  in  these  cases, 
A  small  rubber  drainage  tube  is  drawn  through  a  larger  tube,  the  perforated 
end  is  introduced  into  the  cystic  duct,  and  it  is  held  in  place  by  one  or  more 
catgut  sutures,  which  pass  through  the  outer  tube  but  do  not  touch  the  inner 
tube.  By  the  time  the  catgut  is  absorbed,  it  is  time  to  withdraw  the  drainage 
tube. 

The  abdominal  wound  is  closed  as  in  the  previous  operation,  and  the  tissues 
are  prevented  from  adhering  to  the  gauze  by  the  interposition  of  rubber  tissue. 

During  the  past  few  j^ears  the  operation  of  cholecystectomy  has  been 
done  very  much  more  frequently  than  in  former  years,  chiefly  because  of  the 
fact  that  the  results  following  cholecystotomy  have  been  unsatisfactory  in 
the  hands  of  many  surgeons.  In  our  experience  this  has  been  the  case  almost 
exclusively  in  cases  in  which  we  made  use  of  the  rubber  drainage  tube  for 
the  gall-bladder,  instead  of  packing  it  with  gauze.  We  have,  however,  always 
removed  the  gall-bladder  in  cases  in  which  this  organ  seemed  to  have  been 
severel}^  damaged  by  disease,  or  in  cases  in  which  the  cystic  duct  had  been 
damaged. 

Since  the  introduction  of  almost  universal  cholecystectomy,  scarcely  a 
week  passes  but  that  we  see  in  our  clinic  cases  which  have  had  their  gall- 
bladders removed  and  who  seem  to  be  in  a  very  much  worse  condition  than 
they  were  before  they  had  been  operated  upon,  according  to  their  story. 
It  is  quite  likely,  however,  that  these  cases  greatly  exaggerate  their  symptoms, 
but  our  experience  in  this  direction  has  caused  us  to  doubt  the  efficiency  of 
cholecystectomy,  except  in  cases  in  which  the  above  indications  are  present. 

Occasionally  it  is  not  possible  to  determine  with  certainty  the  point  at 
which  the  common  duct  and  the  cystic  duct  and  the  hepatic  duct  join.  In 
these  cases  it  is  difficult  to  determine  the  correct  point  at  which  the  forceps 
(shown  on  the  following  page)  should  be  applied.  If  they  are  applied  prox- 
imally  to  the  proper  position,  a  portion  of  the  neck  of  the  gall-bladder  will 
remain  and  may  give  rise  to  further  trouble.  If  they  are  placed  too  far 
down,  the  hepatic  duct  is  likely  to  be  injured.  In  these  cases  it  is  better  to 
empty  the  gall-bladder,  as  described  in  connection  with  the  operation  of 
cholecystostom3^  and  to  pack  the  gall-bladder  with  gauze  and  then  proceed 
to  remove  the  organ  from  its  distal  portion  toward  the  cystic  duct,  which  can 
readily  be  recognized  when  it  is  reached.  For  this  purpose  the  peritoneum 
should  be  cut  half  a  cm.  from  the  edge  of  the  liver  down  to  the  mucous  mem- 
brane of  the  gall-bladder,  and  this  should  be  enucleated.  Any  small  bleeding 
points  can  be  caught  as  they  are  encountered.  If  the  cj^stic  duct  has  been 
exposed,  it  can  be  treated  as  described  in  the  previous  operation. 

CHOLEDOCHOTOMY 

In  operation  upon  the  common  duct  a  sand  bag  is  always  placed  under  the 
back  opposite  the  liver,  as  advised  by  Mayo  Robson.  The  usual  straigLt  in- 
cision is  made  through  the  right  rectus  muscle.     If  it  is  found  necessary  to 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


523 


open  the  common  duct  and  more  room  is  desired,  the  incision  is  carried  upward 
and  in^yards  between  the  right  costal  margin  and  the  ensiform  cartilage.  Xoay 
by  lifting  the  lower  edge  of  the  liver  out  of  the  wound,  it  will  be  found  that 
the  gall  bladder  and  the  cystic  and  common  ducts  will  be  brought  into  plain 
view.     The  liver  is  held  in  this  position  by  an  assistant  who  grasps  its  lower 


Excision  of  the  Gall  Bladder. 

Two  pairs  of  forceps  are  in  place,  one  grasping  tlie  neck  of  the  gall  bladder  at  its  entrance 
into  the  cystic  duct,  the  other  grasping  the  cystic  duct  just  below  this  point.  Both  forceps 
also  grasp  the  cystic  artery.  A  dotted  line  indicates  the  position  of  a  stone  in  the  neck  of 
the  gall  bladder  wedged  in  and  obstructing  the  latter.  The  gall  bladder  is  to  be  removed 
from  below  upward,  the  forceps  applied  to  the  neck  of  the  gall  bladder,  including  the  cystic 
artery,  making  the  operation  almost  bloodless. 

(Taken  from  Dr.  AV.  J.  Mayo's  original  drawings.) 


edge  with  his  fingers  covered  with  a  piece  of  dry  gauze.  When  the  liver  is 
held  in  this  position  it  will  be  found  that  the  cystic  and  common  ducts  make 
an  almost  straight  passage  from  the  neck  of  the  gall  bladder  to  the  entrance 
into  the  duodenum. 

If  there  are  adhesions  about  the  ducts  these  are  separated  and  a  spoon  is 
placed  in  the  kidney  pouch  and  the  entire  field  of  operation  protected  by 
sterile  pads. 


524 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


The  stone  is  located  and  grasped  between  the  thumb  and  finger  of  the  left 
hand.  "While  the  stone  is  held  in  this  position,  two  catgut  sutures  are  placed 
into  the  side  of  the  common  duct  directly  over  the  stone.  These  sutures  are 
left  long.  A  little  tension  is  made  upon  the  sutures,  then  the  duct  is  opened 
by  making  a  longitudinal  incision  between  the  two  sutures  directly  over  the 
stone. 


Excision  of  the  Gall  Bladder  Beginning  from  Below. 

A  ligature  has  been  placed  around  the  cystic  duct.  The  neck  of  the  gall  bladder  just 
above  the  cystic  duct  is  grasped  by  forceps  to  prevent  leakage.  A  dotted  line  indicates  the 
position  of  a  stone  wedged  into  the  neck  of  the  gall  bladder  and  causing  complete  obstruction. 
The  cystic  duct  and  the  common  duct  are  also  shown.  Sutures  are  in  place  to  close  the  space 
formed  by  the  loosening  of  the  gall  bladder. 

(Taken  from  Dr.  W.  J.  Mayo's  original  drawings.) 

One  of  the  accompanying  plates  illustrates  a  stone  in  the  common  duct,  and 
two  catgut  sutures  applied  to  each  side  of  the  proposed  incision  and  the  incision 
made  directly  over  the  stone. 

After  all  obvious  stones  have  been  removed,  the  finger  should  be  passed 
into  the  duct  to  detect  any  stones  that  might  be  above  or  below  the  incision. 

Any  sand  or  thick  bile  is  removed  by  packing  strips  of  gauze  into  the  duct 
in  the  manner  described  in  sponging  out  the  gall  bladder.    When  the  duct  is 


SUEGERY  OF  THE  GALL  BLADDER  AND  LIVER  525 

clear,  the  incision  in  it  may  be  closed,  by  suture  or  may  be  drained.  If  there 
is  not  much  evidence  of  infection  of  the  common  duct,  and  the  gall  bladder 
looks  healthy  and  the  cystic  duct  is  patent,  the  wound  in  the  common  duct 
can  be  closed  with  safety,  leaving  drainage  of  the  bile  through  the  gall  bladder 
only.  The  incision  in  the  duct  is  closed,  by  first  approximating  the  edges  with 
a  fine,  continuous  catgut  stitch,  and  over  this  a  few  Lembert  stitches  of  silk. 
A  cigarette  drain  is  placed  down  to  the  common  duct  and  brought  up  out  of 
the  incision  by  the  side  of  the  gall  bladder  drain. 

The  majority  of  the  cases  require  drainage  of  the  common  duct,  especially 
in  those  where  the  head  of  the  pancreas  is  enlarged  from  chronic  pancreatitis. 

A  double  drainage  tube  as  shown  in  figure  (e),  is  inserted  into  the  common 
duct  and  carried  upwards  towards  the  hepatic  duct.  The  two  catgut  sutures 
which  were  placed  in  the  sides  of  the  duct  are  now  utilized  to  fasten  the  drain- 
age tube  in  place,  which  is  done  by  passing  the  sutures  through  the  outer  rub- 
ber tube  and  tying.    These  sutures  are  still  left  long. 

Now  a  piece  of  iodoform  gauze  is  packed  around  the  tube  and  brought  up 
out  of  the  wound  by  the  side  of  the  drainage  tube  to  further  protect  the  peri- 
toneal cavity.  These  same  sutures  are  now  passed  through  the  gauze  and 
tied  so  that  there  can  be  no  displacement  of  the  gauze  should  the  patient  vomit 
after  the  operation. 

The  operation  is  completed  by  closing  the  wound  in  the  usual  manner. 

CHOLECYSTENTEROSTOMY 

This  operation  is  indicated  in  cases  in  which  there  is  a  permanent  obstruc- 
tion between  the  entrance  of  the  hepatic  duct  into  the  common  duct  and  the 
opening  of  the  later  into  the  duodenum,  also  in  cases  of  chronic  interstitial 
pancreatitis. 

The  entire  alimentary  canal  should  be  thoroughly  emptied  before  the 
operation  is  undertaken,  by  the  administration  of  two  large  doses  of  castor 
oiJ,  twelve  to  twenty-four  hours  apart,  then  a  careful  anastomosis  from  one- 
half  to  one  inch  in  length  should  be  made  by  any  one  of  the  various  methods 
employed  in  making  intestinal  anastomosis  with  needle  and  thread. 

If  a  mechanical  device  is  employed,  the  small  Murphy  button  should  be 
chosen,  but  the  suture  seems  to  be  a  superior  method. 

After-treatment.  AVhen  the  operation  is  completed  a  dry,  sterile,  gauze 
dressing  is  applied  and  held  in  place  by  an  abdominal  bandage  applied  tightly, 
so  that  if  vomiting  should  occur,  the  wound  Avill  receive  some  support  from 
the  bandage. 

No  water  is  allowed  by  mouth  until  the  ether  sickness  and  the  nausea  are 
over.  If  the  thirst  is  great  the  mouth  may  be  flushed  frequently  with  Avater 
and  an  enema  of  a  pint  of  salt  solution  may  be  given. 

If  the  pain  is  severe,  morphia  in  doses  of  %  to  %  of  a  grain  may  be  given 
hypodermically. 

Four  to  eight  ounces  of  normal  salt  solution  are  given  as  an  enema  every 
four  hours  for  the  first  twenty-four  hours.  Then  nourishing^  enemata  in  the 
form  of  liquid  peptonoids,  one  ounce,  with  normal  salt  solution  four  ounces, 
are  administered  every  four  hours,  for  two  or  three  days. 

As  soon  as  the  sickness  from  the  anesthetic  is  over,  small  quantities  of 
water  may  be  given  by  mouth,  and  on  the  third  or  fourth  day  beef-tea  or  broth 
may  be  allowed,  increasing  the  diet  slowly  from  this  time  on. 

The  wound  is  dressed  daily  with  dry,  sterile  gauze,  and  on  the  fourth  day 
the  gauze  is  removed  from  the  gall  bladder  and  a  rubber  tube  substituted, 
which  in  ordinary  cases  is  removed  at  the  end  of  a  week  or  ten  days,  and  the 
wound  allowed  to  close. 


526 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


527 


H 

< 
ft> 

^ 
&- 

R 

CD 

o 

y 

CD 

*1 

lit! 

ID 

r+ 

& 

o 
< 

CD 

•-J 

t 

rl- 

o 

Cf 

CD 

CD 

rn 

IQ 

►t-I 

CD 

P 

CD 

5-3 


r-*^ 


O   Oj 

Cfi 


§^g 


?  CD 

Is" 


!:<  2  &• 

ST.  CD  C 
o  &,  s 

B   •      P 

Oq 

t^CD 

CD    (i 
P    i^ 


en   Oj 

cd'p 
&2 


528 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


In  cases  accompanied  by  pancreatitis  or  a  marked  cholangitis,  the  drainage 
is  continued  for  a  period  of  from  two  to  four  weeks. 

The  stitches  are  removed  on  the  twelfth  daj'  and  the  patient  allowed  to  get 
up  at  the  end  of  fourteen  to  eighteen  days. 

CONSTRICTION  OF  THE  DUODENUM  BELOW  THE  ENTRANCE  OF  THE 

COMMON  DUCT 

Several  years  ago  our  attention  was  first  directed  to  an  interesting  condi- 
tion which  is  frequently  present  in  patients  who  come  under  observation 
during  gall-bladder  and  stomach  operations. 

In  many  of  these  cases  the  duodenum  is  distended  with  gas  to  a  point 
just  below  the  entrance  of  the  common  duct,  while  below  this  it  is  contracted, 
and  upon  raising  the  transverse  colon  and  finding  the  origin  of  the  jejunum, 


Illustrating    Mayo    Robsox  's    Position    of   the    Patient   During    Operation    Upon    the 

Common  Duct. 


this  portion  of  the  intestine  will  also  be  found  contracted.  In  looking  over 
authorities  upon  the  subject  of  anatomy,  we  found  they  all  state  that  the 
third  portion  of  the  duodenum  is  the  narrowest  part  of  this  intestine  if  they 
make  any  statement  upon  the  subject.  They  also  state  that  the  first  portion 
of  the  duodenum  is  usuall}^  found  stained  with  bile  after  death.  Several 
further  clinical  observations  pointed  in  the  same  direction.  It  was  found  that 
the  dilatation  of  the  upper  portion  of  the  duodenum  was  most  commonly 
present  in  patients  suffering  from  chronic  cholecystitis  with  sand  or  gall  stones 
in  the  gall-bladder.  In  these  cases  there  was  frequently  a  more  or  less  marked 
enlargement  of  the  pancreas. 

In  having  the  vomitus  examined  systematically  for  a  considerable  period 
of  time  in  patients  who  had  been  subjected  to  general  anesthesia  for  opera- 
tion, it  was  found  that  it  invariably  contained  bile,  showing  that  there  must 
be  some  reason  why  this  fluid  should  be  forced  upward  past  the  pyloric  sphinc- 
ter rather  than  downward  through  the  small  intestine. 

Again,  it  was  found  that  in  patients  suffering  from  acute  gall-stone  colic, 


SURGERY  OF  THE  GALL  BLADDER  AXD  LIVER 


529 


the  spasmodic  pain  -^voulcl  subside  invariably  within  a  few  hours  upon  making 
careful  gastric  lavage  and  prohibiting  the  introduction  of  any  kind  of  food 


T^Pyloj^us;  L.C,  common  duct;  iD.ofJi^,  duct  ofWirsuh^,    S ,  a 
doulle  s-pkinctet- 


p.,    Pijlorus;    D.C.,  com^von  duct ,      Z).  of  74^. ^  c/ u ct  of  M'ir s u n^ ; 
^.^  point  of  qr-eatcst    di:V€io/:,rne>it  of  c^jrculah   jvascl^  filxi-e . 


Shows  Drawings  of  Two  Speciiiexs  EEixovED  from  the  Cadaver,  Showing  the  Location 
OF  the  Circular  Muscle  Fibers  of  the  Duodenum. 

into  the  stomach,  although  without  this  aid  large  doses  of  morphine,  given 
h}T)odermically,  had  produced  at  best  only  temporary  relief. 

This  seemed  to  indicate  that  there  must  be  some  point  near  the  entrance 
of  the  common  duct  into  the  duodenum  which  regulates  the  passage  of  food 
through  this  intestine. 


530  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

These  clinical  observations  induced  us  to  make  a  careful  anatomical  study 
of  this  portion  of  the  small  intestine,  both  in  the  living  patient  and  in  the 
cadaver. 

An  assistant,  Dr.  E.  W,  Thuerer,  made  a  careful  examination  of  the  duo- 
denum in  thirty-nine  cadavers,  which  revealed  in  every  specimen  an  anatom- 
ical condition  of  the  duodenum  consisting  in  a  marked  thickening  of  the 
circular  muscle  fibres  of  this  portion  of  the  alimentary  canal  at  a  point  below 
the  entrance  of  the  common  duct.  The  accompanying  illustration  shows  a 
drawing  of  two  typical  specimens  removed. 

A  considerable  variation  was  found  in  the  exact  position  of  these  muscle 
fibres.  In  some  instances  they  were  arranged  in  a  narrow  circular  band 
forming  a  distinct  sphincter;  in  others  the  thickening  was  diffused,  making 
a  broad,  circular  band ;  and  in  a  few  instances  the  thickening  was  in  two 
different  bands,  with  an  intervening  portion  in  which  the  circular  muscle  fibres 
were  of  the  same  thickness  as  the  remaining  portion  of  the  duodenum. 

There  was  a  further  difference  in  the  location  of  this  duodenal  sphincter ; 
in  most  specimens  it  was  located  from  3  to  10  cm,  below  the  point  of  entrance 
of  the  common  duct,  while  in  a  few  instances  a  portion  of  the  sphincter 
included  a  point  of  entrance  of  the  common  duct,  the  remaining  portion, 
however,  being  always  located  below  this  point. 

These  conditions  seem  to  explain  a  number  of  physiological  facts ;  that 
vomiting  when  the  stomach  is  relatively  empty  always  expels  a  certain  amount 
of  bile ;'  and  that  in  many  cases  in  which  there  is  a  dilatation  of  the  stomach 
without  constriction  of  the  pylorus,  with  an  ulcer  in  the  pyloric  end,  the  ulcer 
frequently  extends  into  the  duodenum.  It  may  also  explain  some  of  the 
stomach  symptoms  which  are  so  constantly  observed  in  connection  with  gall 
stone  disease.  It  will  also  explain  a  condition  not  infrequently  encountered 
in  operating  for  the  relief  of  gall  stones  and  ulcer  of  the  stomach,  that  is,  the 
presence  of  a  greatly  distended  duodenum,  with  a  completely  contracted  first 
portion  of  the  jejunum. 

It  also  explains  the  presence  of  the  bile-staining  of  the  portion  of  the 
duodenum  above  the  common  duct  in  the  cadaver,  while  the  portion  below  this 
point  is  usually  free.    This  has  been  noted  by  many  observers. 

It  has  seemed  as  though  this  arrangement  of  circular  muscle  fibres  served 
the  purpose  of  a  sphincter  to  facilitate  the  process  of  mixing  the  bile  and  the 
pancreatic  juice  in  the  duodenum ;  which  has  been  so  perfectly  described  by 
Cannon. 

The  presence  of  a  gastric  ulcer  in  a  considerable  proportion  of  patients 
that  have  suffered  from  chronic  appendicitis  may  have  some  relation  to  this 
condition  in  the  following  manner:  There  is  undoubtedly  an  obstruction  of 
the  ileocecal  valve,  due  to  the  physiological  contraction  of  this  sphincter  dur- 
ing an  acute  exacerbation  of  appendicitis,  for  the  purpose  of  establishing  a 
condition  of  rest  in  this  vicinity.  This  is  followed  by  nausea  and  vomiting, 
and  it  seems  reasonable  to  suppose  that  the  ileocecal  valve  initiates  return 
peristalsis  and  that  this  in  turn  excites  a  contraction  of  the  duodenal  sphincter 
and  the  pyloric  sphincter,  and  that  in  this  Avay  a  normal  passage  of  food  from 
the  stomach  into  the  intestines  is  interfered  wath,  causing  an  accumulation  of 
residual  food  in  the  stomach,  and  that  the  irritation  caused  in  this  manner 
may  be  an  etiological  factor  in  the  production  of  gastric  ulcer.  It  may  also 
explain  the  presence  of  bile  in  the  vomitus  of  patients  suffering  from  intestinal 
obstruction. 

ABSCESS  OF  THE  LIVER 

Cases  of  suppuration  in  the  liver,  other  than  those  found  in  tropical  coun- 
tries, are  usually  due  to  metastases  of  pyemia. 

Dysentery  is  far  the  most  frequent  cause  of  abscesses  of  the  liver.     They 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER  531 

are  verj^  common  in  the  tropical  countries  where  the  various  inflammatory 
conditions  of  the  bowels  produce  a  thrombo-phlebitis  of  the  mesenteric  A^ein; 
the  clots  decompose,  become  dislodged  and  carry  the  infection  through  the 
branches  of  the  portal  vein,  resulting  in  abscesses  of  the  liver. 

The  amebge  dysenteric  have  frequently  been  found  in  the  pus  from  these 
abscesses. 

Liver  abscesses,  other  than  those  occurring  during  the  course  of  dysentery, 
may  be  due  to  gall  stones,  t^q^hoid  fever,  intestinal  ulcers,  inflammation  in 
region  of  the  portal  vein,  trauma,  syphilis  and  also  as  one  of  the  complications 
following  a  suppurative  appendicitis.  It  also  has  resulted  from  actinomycosis 
of  the  liver. 

Symptoms.  The  most  constant  symptoms  are,  first,  a  history  in  which 
dysentery  and  chill  appear;  second,  general  malaise  pronounced;  third,  pain 
and  tenderness  over  liver;  fourth,  enlargement  of  the  liver;  fifth,  hectic  sweats, 
and  rigors ;  sixth,  right-side  posture ;  seventh,  erratic  temperature  running 
from  96.5  to  103.5°  F. ;  eighth,  progressive  emaciation;  ninth,  gastric  disturb- 
ances. 

Pain  in  region  of  liver  is  usually  an  early  and  prominent  symptom.  The 
pain  often  follows  the  course  of  the  phrenic  and  fourth  cervical  nerves  and 
radiates  toward  the  right  shoulder.  It  is  usually  constant  from  the  onset.  By 
carefully  noting  the  exact  limits  of  the  pain  and  tenderness  the  abscess  may 
often  be  located.    Pain  is  always  increased  by  digital  pressure. 

Enlargement  of  the  liver  is  perhaps  the  most  invariable  ob.jective  symptom, 
and  usually  causes  a  bulging  of  the  right  hj'pochondrium.  The  enlargement 
may  take  place  in  any  direction.  The  expansion  takes  the  course  of  the  least 
resistance  and  may  be  the  means  of  determining  the  seat  of  the  abscess. 

Prognosis.  The  prognosis  is  unfavorable  especially  in  cases  of  multiple 
abscesses.  The  patient  may  succumb  to  the  primary  infectious  disease,  or  to 
pyemia  or  sepsis,  or  the  abscesses  may  rupture  into  the  peritoneal  cavity,  caus- 
ing a  septic  peritonitis,  or  may  rupture  into  the  pleural  cavity  resulting  in 
septic  pneumonia. 

Treatment.  The  treatment  is  operative.  The  liver  must  be  reached  by 
crossing  either  the  pleura  or  the  peritoneum,  the  route  chosen  according  to  the 
location  of  the  abscess.  If  there  is  reason  to  believe  that  the  abscess  is  not 
pointing  toward  the  pleura,  or  has  not  ruptured  into  it.  the  liver  is  reached 
through  the  peritoneal  cavity  by  making  an  incision  high  up  through  the 
right  rectus  abdominis  muscle.  The  abdominal  cavity  is  carefully  walled  off 
by  gauze  pads.  If  the  abscess  is  not  readily  discovered,  the  liver  may  be 
explored  by  means  of  an  aspirating  needle.  The  abscess  is  then  incised  freely 
and  the  cavity  packed  with  iodoform  gauze.  Other  pieces  of  iodoform  gauze 
are  so  arranged  as  to  protect  the  general  peritoneal  cavity  and  brought  out 
through  the  incision. 

In  cases  in  which  the  abscess  is  evident  on  exposure  of  the  liver,  the  opera- 
tion may  be  done  in  two  stages.  The  surface  of  the  liver  at  the  point  of 
suppuration  is  exposed,  and  the  wound  packed  with  iodoform  gauze  and  left 
three  or  four  days  until  adhesions  have  formed,  and  then  the  operation  is 
completed. 

In  passing  through  the  pleura,  it  is  necessary  to  resect  one  or  more  ribs. 
"When  the  parietal  pleura  is  incised  its  edges  are  caught  by  hemostatic  for- 
ceps. The  diaphragmatic  pleura  is  now  incised  and  its  margins  sewed  to  those 
of  the  parietal  pleura  so  as  to  close  the  pleural  cavity.  The  operation  is  com- 
pleted by  incising  through  the  diaphragm  and  draining  the  abscess  freely. 

In  cases  in  which  there  is  redness  and  edema  of  the  skin,  making  it  evident 
that  adhesions  exist,  the  abscesses  may  be  incised  directly. 


532  SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 

HYDATIDS  OF  THE  LIVER 

This  disease  is  caused  by  a  parasite  knoAvn  as  the  tenia  echinococcus  whose 
normal  habitat  is  in  the  intestinal  canal  of  dogs,  jackals  and  wolves. 

The  disease  is  most  prevalent  in  Australia  and  Iceland,  where  the  natives 
are  not  cleanly  and  live  in  close  association  with  dogs. 

The  tenia  are  taken  into  the  alimentary  canal  with  the  food,  or  more  com- 
monly with  drinking  water.  According  to  Fowler  their  albuminous  envelope 
is  partly  digested  in  the  stomach,  and  thus  set  free  they  burrow  into  the  tissues 
and  most  frequently  enter  a  radicle  of  the  portal  vein  and  are  thus  carried 
to  the  liver. 

There  is  some  question  as  to  what  becomes  of  the  liver  tissue  where  these 
large  cysts  develop  in  the  organ.  Some  authors  believe  that  an  atrophy  takes 
place,  while  others  think  that  a  hypertrophy  occurs. 

AVhen  the  cj^st  is  fully  developed  there  is  a  sac  filled  with  fluid  in  which 
float  smaller  cysts  known  as  daughter  cysts,  and  sometimes  there  are  tertiary 
cysts  inside  of  these. 

The  booklets  of  the  parasite  are  usually  found  in  the  cyst  wall. 

The  cyst  may  exist  for  many  years  and  only  be  discovered  at  autopsy. 
The  great  danger  is  that  they  may  rupture.  However,  this  is  not  necessarily 
fatal,  as  they  may  rupture  externally  or  into  the  intestinal  canal.  A  cure  may 
result  in  this  manner.  If  the  rupture  occurs  into  the  pleural  cavity,  gall 
bladder  or  peritoneal  cavitj^  it  is  almost  invariably  fatal.  If  infection  occurs, 
the  disease  may  resemble  a  liver  abscess. 

Symptoms.  The  symptoms  vary  according  to  the  size  and  location  of  the 
cyst.  When  large  and  near  the  surface  it  may  be  felt  as  a  globular  tumor, 
rather  elastic  and  sometimes  fluctuating.  If  the  tumor  is  behind  the  liver,  there 
may  be  no  symptoms  at  all.  Most  patients  complain  of  a  sense  of  distress  and 
weight  in  the  hepatic  region.  As  the  tumor  grows  there  may  be  pressure 
symptoms,  as  dyspnea  and  cough  from  extension  upwards  to  the  diaphragm. 
Pressure  on  the  portal  vein  may  result  in  ascites,  jaundice  or  hemorrhoids. 
The  hydatid  fremitus  is  seldom  present.  It  is  only  present  when  the  daughter 
cysts  swim  in  the  fluid. 

Diagnosis.  The  diagnosis  is  often  difficult,  as  many  of  these  patients  may 
remain  in  good  health  for  years.  It  may  be  differentiated  from  cancer  and 
abscess  by  the  long  history,  slow  growth,  the  absence  of  loss  of  weight  and 
the  lack  of  the  pronounced  constitutional  symptoms  present  in  abscess.  Its 
shape  and  absence  of  biliary  symptoms  rule  out  gall  bladder  disease.  The 
fact  that  the  colon  does  not  overlie  the  tumor,  rules  out  cystic  or  sarcomatous 
kidney. 

The  complement  fixation  test  has  proved  of  striking  value  in  the  diagnosis 
of  these  cases.  The  patient's  serum  is  tested  for  antibodies,  precisely  as  in  the 
Wassermann  test,  save  that  echinococcus  cyst  fluid  (from  slaughter  house)  is 
used  as  antigen. 

An  interesting  diagnostic  point  in  palpating  an  hydatid  cyst  is  a  peculiar 
vibration  that  persists  for  quite  a  while  after  tapping  against  the  tumor.  The 
vibration  is  due  to  the  motion  set  up  in  the  daughter  and  grand-daughter  cysts. 

Treatment.  The  treatment  consists  of  evacuation  of  the  cyst  contents  and 
removal  of  the  lining  of  the  cyst  cavity  and  drainage  of  its  cavity,  or,  in  a  few 
selected  cases  where  the  cyst  is  pedunculated,  excision  of  the  entire  cyst. 

The  operation  of  drainage  of  the  cyst  may  be  done  in  two  stages,  after  the 
method  of  Volkmann,  which  consists  of  opening  the  peritoneal  cavity  and 
placing  sterile  gauze  pads  between  the  cyst  wall  and  the  peritoneum  to  cause 
adhesions  to  form  between  the  liver  and  the  peritoneum,  or  suturing  the  cyst 
wall  to  the  peritoneum,  and  three  or  four  days  later  opening  and  draining 
the  cyst. 


SUEGERY  OF  THE  GALL  BLADDER  AND  LIVER 


533 


The  operation  most  commonly  done  consists  of  making  an  incision  over 
the  most  prominent  part  of  the  swelling,  then  carefully  packing  away  the 
stomach  and  intestines  with  sterile  gauze  pads ;  a  trocar  is  inserted  into  the 
cyst  and  as  much  fluid  as  possible  is  withdrawn.  The  cyst  is  then  incised 
and  the  remainder  of  its  contents  sponged  out.  The  lining  of  the  cyst,  which 
is  known  as  the  parasite  endocyst,  is  removed.  The  edges  of  the  cyst  are 
sutured  to  the  peritoneum  and  the  cyst  cavity  packed  with  gauze. 

The  after-treatment  consists  in  gradually  diminishing  the  amount  of  pack- 
ing at  each  dressing  until  the  cvst  cavitv  is  obliterated. 


L,  Liver.     S,  Section  EEiiovED.     (Feaxk.) 
INJURIES  OF  THE  LIVER 


The  liver  is  apt  to  be  injured  by  crushing  accidents,  as  when  a  heavy 
wagon  wheel  passes  over  the  body;  also  by  blows  or  falls  which  break  one  or 
more  ribs,  which  puncture  the  liver,  or  from  penetrating  wounds. 

The  symptoms  of  rupture  of  the  liver  are  those  of  internal  hemorrhage  and 
severe  shock,  such  as  extreme  pallor  and  cold  skin,  feeble  and  rapid  pulse, 
sighing  respiration;  the  abdomen  becomes  swollen  and  tympanitic  and  some- 
times there  is  dullness  from  the  collection  of  blood.  Often  there  is  vomiting, 
thirst  and  syncope. 


534 


SURGERY  OF  THE  GALL  BLADDER  AND  LIVER 


Treatment.  The  treatment  should  be  directed  toward  the  control  of 
hemorrhage  as  soon  as  possible  and  to  prevent  the  retention  of  bile  in  the 
peritoneal  cavity  on  account  of  its  liability  to  cause  cholemia. 

If  from  the  site  of  injury  it  is  thought  that  the  injury  to  the  liver  is  in  the 
left  lobe,  or  is  undetermined,  it  is  well  to  make  a  median  incision. 

In  wounds  of  the  right  lobe  a  longitudinal  incision  is  made  through  the 
outer  edge  of  the  right  rectus  abdominis  muscle  and  then,  if  found  necessary, 
this  may  be  converted  into  the  "S  "-shaped  incision,  as  suggested  by  Bevan, 
or  into  the  Robson  incision. 


L,  Liver  with  Wound  Partially  Sutured.     (Frank.) 


Wounds  of  the  liver  may  be  treated  by  suture  or  cautery  or  by  gauze 
tampon,  or  by  suturing  a  piece  of  sterile  gauze  down  upon  the  bleeding  surface. 

In  the  majority  of  cases  a  little  pressure  by  means  of  a  gauze  pad  for  a 
few  minutes  will  control  the  hemorrhage.  In  some  cases  it  may  be  necessary 
to  make  continuous  pressure  over  the  bleeding  surface.  This  may  be  done  by 
suturing  a  piece  of  iodoform  gauze  over  the  bleeding  surface  by  a  few  catgut 
stitches  and  bringing  one  end  up  through  the  abdominal  wall.  The  gauze  will 
make  continuous  pressure  and  the  stitches  will  prevent  the  displacement  of 
the  gauze  should  the  patient  cough  or  vomit.  The  catgut  will  be  absorbed  in 
a  few  days  so  that  the  gauze  may  then  be  readily  removed.  Bleeding  may  also 
be  controlled  by  suturing  the  liver,  using  a  non-cutting  needle  threaded  with 
catgut.     The  sutures  are  passed  directly  through  the  liver  substance,  then 


SURGERY  OF  THE  GALL  BLADDER  AND  LITER  535 

tied  just  tigh.t  enough,  to  bring  the  edges  of  the  liver  together  i^the  blood  pres- 
sure in  the  liver  is  very  low  and  is  controlled  by  slight  pressure^. 

In  large  wounds  with  considerable  destruction  of  liver  tissue  it  is  better 
to  use  the  method  of  suture  devised  by  Frank.  This  consists  in  the  exci- 
sion of  a  portion  of  the  liver,  as  shown  in  the  plate,  removing  a  wedge-shaped 
piece,  leaving  the  organ  with  two  flaps  forming  a  trough.  If  there  is  much 
bleeding  from  the  cutting  of  the  liver  tis.sue,  it  is  controlled  by  ligating  the 
bleeding  vessel,  or  by  passing  a  mattress,  catgut  suture  through,  the  entire 
thickness  of  the  liver  surrounding  the  vessel.  The  flaps  are  now  coaptated. 
For  this  purpose  a  long,  non-cutting  needle  is  threaded  with  catgut  and  a 
running  stitch  is  commenced  at  one  end  and  continued,  as  follows  (see  plate j  : 
One  suture  is  carried  through  the  liver  tissue  near  the  bottom  of  the  trough 
and  then  one  superficially,  and  so  on  alternating.  The  stitches  should  not  be 
tight,  but  drawn  just  enough  to  bring  the  two  tied  flaps  together  in  perfect 
coaptation,  obliterating  all  dead  space.  The  continuity  of  the  liver  surface  is 
re-established  and  no  raw  surface  or  ragged  edge  is  left. 


PART  VIII 

SURGERY  OF  THE  GENITO-URINARY  TRACT 


General  remarks.  In  considering  the  surgery  of  the  kidney  especial  stress 
should  be  laid  upon  diagnosis,  because  this  is  really  the  most  difficult  task 
connected  with  the  subject.  The  examination  of  urine  is  most  important,  but 
it  does  not  in  itself  result  in  a  definite  surgical  indication.  The  presence  of 
albumen,  tube  casts  and  characteristic  epithelial  cells  from  the  kidney  indi- 
cate nephritis  in  one  or  both  kidneys,  but  it  does  not  make  a  surgical  diagnosis. 
The  presence  of  blood  or  pus  indicates  a  bleeding  or  suppurating  point  in  the 
kidney,  the  ureter,  the  bladder  or  the  urethra,  but  again  it  does  not  definitely 
locate  the  diseased  region ;  consequently  these  findings  can  act  only  as  corrob- 
orative evidence  and  serve  but  to  confirm  a  diagnosis  made  without  their 
aid.  It  is  in  such  cases  that  it  is  important  to  obtain  the  urine  from  each 
kidney  separately,  so  as  to  locate  the  source  of  these  substances  and  determine 
the  diseased  organ.  ■  At  the  same  time  it  is  possible  to  learn  whether  the  other 
kidney  is  sufficiently  active  to  be  depended  upon  to  perform  the  entire  Avork. 
In  the  female  this  can  be  done  with  comparative  ease  through  a  large  specu- 
lum, the  patient  being  placed  in  the  knee-chest  position  and  the  bladder 
permitted  to  infiate  itself  with  air,  which  it  does  spontaneously  whenever  a 
speculum  is  inserted  with  the  patient  in  the  position  named.  In  the  male,  it 
may  be  accomplished  by  the  aid  of  a  eystoscope. 

It  is,  however,  to  be  remembered  that  the  opening  of  the  ureter  into  the 
bladder  is  a  delicate  mechanism  which  frequently  prevents  infectious  material 
existing  in  the  bladder  from  infecting  the  ureter  and  the  kidney  for  a  long 
period  of  time,  and  also  that  in  cases  in  which  one  suspects  a  diseased  kidney 
the  bladder  is  very  frequently  not  aseptic  and  one  consequently  runs  the 
risk  of  infecting  the  other  kidney  also  by  carrying  septic  material  from  the 
bladder  into  the  ureter.  Moreover,  it  is  likely  that  after  the  ostium  of  the 
ureter  has  once  been  distended  for  the  introduction  of  a  ureteral  catheter  it 
may  no  longer  be  so  certain  to  guard  against  infection  of  the  ureter  and 
kidney  from  the  bladder.  We  have  observed  infections  of  the  kidney  in  a 
considerable  number  of  cases  from  the  practice  of  ureteral  catherization.  It 
therefore  seems  at  the  present  time  to  be  an  unwarranted  procedure,  except  in 
the  hands  of  surgeons  especially  trained  in  the  use  of  the  eystoscope  and 
the  ureteral  catheter;  and  then  only  -nhen  needed  to  make  a  diagnosis  in 
cases  in  which  a  positive  determination  is  of  importance  and  cannot  be  made 
without  recourse  to  this  method. 

The  Harris  segregator.  The  use  of  the  instrument  is  described  by  Harris 
thus : 

"The  instrument  is  used  in  the  following  manner:  The  patient,  male  or 
female,  is  placed  comfortably  on  a  table  in  the  ordinary  lithotomy  position, 
with  the  hips  slightly  elevated.  The  instrument,  with  the  flattened  surfaces 
in  contact  so  as  to  form  practically  a  single  catheter,  is  introduced  into  the 
bladder  in  the  ordinary  way.  As  soon  as  the  proximal,  curved  extremity  is 
within  the  bladder,  the  proper  distance  being  indicated  by  the  graduated  scale, 

537 


538  SURGERY  OF  THE  GENITO-URINARY  TRACT 

each  catheter  is  rotated  about  its  longitudinal  axis  until  each  proximal  end, 
as  indicated  by  the  distal  end,  is  directed  outward  and  backward.  The  end 
of  each  catheter  should  pass  through  an  arc  of  about  110  to  120  degrees,  or  so 
that  the  angle  subtended  posteriorly  by  the  two  catheters  will  be  about  120 
or  140  degrees.  They  are  held  in  this  position  by  a  small  spiral  spring.  The 
ends  of  the  proximal  extremity  will  now  be  in  the  neighborhood  of,  but  not 
exactly  at,  the  ureteral  openings.  The  ends  are  separated  a  greater  distance 
than  the  distance  between  the  ureteral  openings,  so  as  to  avoid  the  danger  of 
compressing  the  opening  of  the  ureter,  and  thus  preventing  the  escape  of  the 
urine.  The  lever  is  now  introduced  into  the  vagina  in  the  female  or  rectum 
in  the  male.  By  gentle  pressure  forward  directly  in  the  mid-line,  the  base  of 
the  bladder  is  raised  into  a  longitudinal  fold  between  the  ureteral  openings, 

"The  curve  of  the  lever  is  such  that  it  fits  nicely  in  the  angle  formed  by 
the  separating  extremities  of  the  catheters,  thus  forming  a  complete  water- 
shed. The  end  of  each  catheter  now  lies  at  the  most  dependent  part  of  a  little 
pocket,  a  perfect  watershed  separating  the  two.  The  ureters  open,  one  on 
either  side  of  the  watershed  near  the  base  of  the  declivity  in  the  immediate 
vicinity  of  the  respective  ends  of  the  catheter. 

' '  By  producing  a  gentle  exhaustion  of  the  air  in  the  vials  by  means  of  the 
bulb,  the  urine,  as  fast  as  it  escapes  from  the  ureters,  drops  directly  into  the 
ends  of  the  catheters  and  flows  at  once  into  the  vials,  right  and  left,  re- 
spectively. 

"The  instrument  and  its  application  are  so  simple  that  its  advantages  are 
apparent  at  once,  and  hence  need  no  arguments  to  support  them. 

"This  being  the  case,  we  may  proceed  at  once  to  dispose  of  any  possible 
objections  that  may  suggest  themselves. 

"The  possibility  of  compressing  the  opening  of  the  ureter  and  thus  pre- 
venting the  escape  of  the  urine  from  that  side  is  obviated,  as  already  men- 
tioned. 

"In  diseased  conditions  of  the  vesical  mucosa  the  value  of  an  examination 
may,  upon  first  thought,  appear  to  be  considerably  lessened,  owing  to  contam- 
ination of  the  urine  with  products  of  vesical  origin.  Upon  reflection,  however, 
this  will  be  found  not  so.  The  bladder,  when  necessary,  should  be  thoroughly 
cleansed  by  irrigation  before  introducing  the  instrument.  After  the  instru- 
ment is  in  place  the  little  pockets  may  be  again  cleansed  by  irrigating  them 
directly  through  the  little  straight  tubes  on  the  distal  end  of  the  instrument 
provided  for  that  purpose. 

"The  urine,  as  fast  as  it  escapes  from  the  ureters,  is  sucked  at  once  into 
the  catheters,  so  that  it  does  not  remain  in  contact  with  the  mucosa.  The  end 
of  the  catheter  is  so  near  the  opening  of  the  ureter  that  the  urine  comes  in 
contact  with  an  extremely  small  portion  of  the  bladder  surface.  The  exam- 
ination is  not  continued  long  enough  at  any  time  for  pus  (for  instance)  to  be 
formed  in  sufficient  quantity  to  be  taken  up  by  the  catheter.  Hence,  it  will  be 
seen  that  contamination,  even  when  the  bladder  is  diseased,  will  be  slight. 

"It  is  likely  that  in  certain  greatly  enlarged  prostates  or  growths  of  the 
so-called  middle  lobe,  or  in  vesical  calculi  or  chronically  inflamed  and  con- 
tracted bladders,  the  instrument  would  not  be  applicable,  but  such  cases  form 
a  very  small  minority  of  those  in  which  its  use  would  be  desirable. 

"The  little  straight  tubes,  when  not  being  used  for  irrigation,  must,  of 
course,  be  closed  air  tight  by  simply  tying  the  little  rubber  tubes  attached  to 
them,  or  passing  the  opposite  ends  of  a  single  tube  over  each  straight  end. 
Aspiration  with  the  bulb  should  not  be  too  great  so  as  to  draw  the  mucosa 
into-  openings  of  the  catheter.  Very  slight  aspiration  is  all  that  is  necessary. 
As  a  few  drops  of  fluid  are  apt  to  remain  in  the  bladder  even  after  the  use  of 
the  catheter,  the  first  few  drops  that  come  over  should  be  discarded. 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


539 


"The  instrument  should  be  opened  carefully  when  in  the  bladder,  so  as  not 
to  excite  hemorrhage  by  injuring  the  mucosa.  The  proximal  curve  should  be 
just  within  the  bladder,  which  is  determined  by  noting  the  length  of  the 
urethra  on  the  scale.  Introduce  the  instrument  into  the  bladder  and  open  it 
before  introducing  the  lever  into  the  vagina  or  rectum.  The  ends  of  the 
catheters  are  easily  felt  through  the  vagina  or  rectum,  and  the  lever  should 


-I      t]       U^I     ^\      r~i      co|       m|        °l      =\        j;|    r^l       J)       ^^       «|      t;i       £  y^^^^ 


Harris'  Segregator. 

be  directly  in  the  middle,  midway  between  the  two  ends,  and  pressed  snugly 
into  the  angle.  Sufficient  pressure  should  not  be  used  to  cause  pain,  as  the 
watershed  is  very  easily  formed.  The  urine  does  not  drop  continually  into 
the  yials,  but  mtermittmgly,  just  as  it  escapes  from  the  ureters.  The  use  of 
the  instrument  is  not  painful  and  does  not  require  an  anesthetic,  except  pos- 
sibly m  an  over-sensitive  or  nervous  patient,  who  would  not  submit  to  any 
manipulation  whatsoever. 


540  SURGERY  OF  THE  GENITO-URINARY  TRACT 

"By  attention  to  these  simple  rules  the  application  of  the  instrument  will 
be  found  very  simple,  and  the  results  all  that  could  be  desired." 

The  instrument  is  contraindicated  only  in  cases  in  which  its  introduction 
is  likely  to  cause  severe  traumatism  on  account  of  the  inflamed  condition  of 
the  urethra  or  the  bladder.  These  cases  can  be  easily  eliminated  and  form 
but  a  very  small  proportion  of  all  those  in  which  one  might  desire  to  make  a 
separate  examination  of  the  urine  from  the  two  kidneys. 

Many  other  instruments  intended  to  accomplish  the  same  end  have  since 
been  invented,  but  none  of  them  seems  to  be  as  reliable  as  the  Harris.  JNIore- 
over,  the  number  of  men  who  can  safely  catheterize  the  ureter  has  increased 
to  such  an  extent  since  the  time  when  this  instrument  was  invented  that  the 
necessity  for  using  such  an  apparatus  is  no  longer  so  marked. 

CYSTOSCOPY 

Direct  vision  of  the  bladder  by  means  of  an  electrically  lighted  instrument 
has  been  used  in  our  clinic  during  the  past  four  years  in  over  500  examina- 
tions, and  has  proven  a  worthy  aid  in  diagnosis  when  used  in  conjunction  with 
the  history  and  physical  findings  in  the  case. 

Indications,  The  cystoscope  is  of  value  in  diagnosing  such  conditions  as 
cystitis,  tuberculosis,  ulcer,  papilloma,  carcinoma,  or  stone  of  the  bladder. 
Ulcers  and  tuberculous  inflammation  can  be  treated  by  local  injections  of 
strong  silver  salts.  Papillomata  and  early  primary  carcinomata  are  cauter- 
ized by  means  of  a  ful,gurating  current.  A  bladder  or  ureteral  stone  can  often 
be  grasped  by  a  forcep  and  removed  directly,  if  not  too  large.  Some  large 
stones  are  soft  enough  to  be  crushed  and  washed  ovit  as  sand.  When  a  stone 
is  larger  than  .8  cm.  and  too  hard  to  be  crushed,  it  can  be  removed  only 
through  a  cystotomy.  By  watching  the  condition  of  the  ureteral  openings  and 
the  character  of  flow  of  urine  coming  from  them,  much  can  be  learned  of  the 
functions  of  the  kidneys.  In  cases  of  obstruction  of  the  ureter,  due  to  condi- 
tions such  as  calculus,  non-shadow-giving  concretion,  or  kink;  or  in  the 
diagnosis  of  hydronephrosis  or  of  renal  tuberculosis,  the  ureters  may  be 
catheterized  and  separate  specimens  of  urine  collected.  Radiographs  may 
be  made  with  the  bismuth-impregnated  catheters  in  position  in  order  to 
demonstrate  the  course  of  the  ureters.  We  have  made  a  very  few  pyelograms, 
as  we  consider  the  injection  of  the  pelvis  of  the  kidney  with  silver  salts  a 
frequently  dangerous  and  usually  unnecessarj'  procedure. 

Contraindications.  A  radiograph  should  always  first  be  made  in  cases  of 
J  suspected  renal,  ureteral  or  cystic  calculus.  When  the  stone  is  definitely 
shown  by  the  radiograph,  it  is  usually  unnecessary  to  use  this  method.  It 
should  not  be  used  in  very  hypersensitive  individuals ;  or,  at  least,  the  exam- 
ination should  be  made  as  rapidly  as  possible  consistent  with  thorough  obser- 
vation. In  cases  of  active  cystitis  or  urethritis,  the  ureters  should  not  be 
catheterized,  as  an  ascending  pyelonephritis  may  result. 

Instruments.  In  all  of  our  cystoscopic  work  we  have  used  but  one  instru- 
ment, that  devised  by  Dr.  Braash  of  the  Mayo  clinic,  and  it  has  been  entirely 
satisfactory  in  all  instances.  It  is  a  direct  vision  type,  there  being  no  lenses 
to  distort  the  view,  and  it  is  very  simpl}^  constructed  and  durable.  Only 
one  insertion  of  the  instrument  is  necessary  for  viewing,  catheterizing  the 
ureters,  fulgurating  or  removing  stones ;  a  fact  of  prime  importance,  especially 
in  the  male.    The  following  is  a  list  of  instruments  which  we  use : 

1  Braash  cystoscope  complete  with  double  catheterizing  tube. 

3  extra  tungsten  lamps. 

1  current  rheostat  and  attaching  cord. 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


541 


2  No.  5  Forges  bismuth  impregnated  ureteral  catheters. 
1  fulgurator-generator   (Wappler). 
1  fulgurating  wire. 
1  operating  forcep. 

1  glass  jar  for  formalin  sterilization  of  instruments. 
Solutions : 

Glycerine.  ' 

10  per  cent,  cocaine. 

1  per  cent,  alypin. 

2  per  cent,  boric  acid. 


Renal  Stone  (a)   in  Pelvis  of  Left  Kidney,     (b)   Catheter  in  Left  Ureter  and  Kidney. 
(c)  Catheter  in  Right  Ureter  and  Kidney. 


Preparation  of  instruments.  All  but  the  glass-containing  metal  instru- 
ments may  be  sterilized  by  boiling  for  one-half  hour.  Those  containing  glass 
may  be  placed  in  phenol  95  per  cent,  for  five  minutes,  then  in  alcohol  95  per 
cent.,  followed  by  rinsing  in  sterile  water.  Or,  better  still,  all  instruments, 
except  the  catheters,  are  well  washed  with  warm  soap  suds,  rinsed,  and 
placed  in  an  upright  jar  containing  strong  fumes  of  formaldehyde.  This  can 
be  accomplished  by  allowing  a  piece  of  gauze  soaked  with  commercial  for- 


542 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


malin  to  remain  in  the  bottom  of  the  jar.  The  catheters  are  siphoned  with 
2  per  cent,  cold  boric  acid  solution  and  put  away  in  a  cool  place.  When  ready 
to  use  they  are  placed  in  a  sterile  bowl  containing  4  per  cent,  boric  acid 
solution. 

The  most  aseptic  precautions  are  indicated  throughout  the  examination 
and  great  care  must  be  exercised  not  to  traumatize  the  parts  in  the  least.  If 
these  precautions  are  not  observed,  annoying  inflammations  may  result  that 
are  worse  than  the  original  condition. 

The  bowels  should  be  thoroughly  cleansed  by  means  of  two  ounces  of 
castor  oil  followed  by  a  large  soap  suds  enema.     This  procedure  is  necessary 


Shadow  in  Eegion  of  Left  Ureter. 


in  all  cases  in  which  radiographs  are  to  be  made  during  the  course  of  the 
examination.  In  extremely  sensitive  individuals,  or  in  those  with  severe  pain 
in  the  region  of  the  urethra  not  controllable  by  the  use  of  cocaine,  it  is  best 
TO  anesthetize,  preferably  with  ether.  It  is  very  seldom  the  case  that  general 
anesthesia  is  necessary.  However,  when  it  is  known  that  an  operation  is  to 
be  performed  after  the  examination,  the  patient  is  always  anesthetized  before 
beginning.  The  patient  is  instructed  to  em.pty  the  bladder  just  before,  in 
order  to  determine  the  amount  of  residual  urine.  One-half  hour  before  be- 
ginning it  is  well,  especially  in  male  patients,  to  give  an  hypodermic  injection 
of  %  or  1/4  grain  of  morphine. 

The  external  genitals  are  thoroughly  cleansed  with  sterile  soap  suds  and 
water,  as  are  the  operator's  hands.    In  fact,  the  aseptic  precautions  must  be 


SUEGERY  OF  THE  GENITO-URINARY  TRACT 


543 


as  great  as  in  a  major  surgical  operation.  A  small  pledget  of  cotton  soaked 
in  10  per  cent  cocaine  solution  is  placed  in  the  external  urethral  meatus  for 
a  period  of  five  minutes  and  then  removed.  A  male  catheter,  lubricated  "with 
sterile  glycerine,  is  passed  into  the  bladder  and  the  residual  urine  drained  and 
saved  for  examination.  Through  the  catheter  one  ounce  of  a  1  per  cent, 
solution  of  ah^Din  or  2  per  cent,  cocaine  is  injected  and  the  catheter  removed. 
The  current  rheostat  is  adjusted  to  give  the  proper  intensity  of  light,  the 
obturator  is  placed  in  position,  the  end  covered  with  sterile  glycerine,  and  it 
is  then  ready  to  be  passed.     In  females  there  is  no  difficulty  in  passing  the 


Catheter  Passed   (C)    with  Obstruction  at  the  Stone   (B] 

Made  Cektain. 


Diagnosis   in  this  Wat 


instrument :  in  males,  however,  it  is  sometimes  necessary  to  pass  sounds  in 
gradually  increasing  sizes  in  order  to  dilate  strictures  that  may  be  present. 
The  obturator  is  now  withdrawn,  the  AvindoAV  placed  in  position  and  the 
bladder  irrigated  through  the  instrument  (with  2  per  cent,  warm  boric  acid 
solution  held  in  a  glass  vessel  placed  4  or  5  feet  above  the  patient).  The 
window  is  nest  placed  in  position  and  the  electrical  connection  made.  The 
bladder  is  then  distended  to  the  point  of  beginning  distress,  when  the  flow 
of  boric  solution  is  discontinued  and  a  little  allowed  to  escape.  "When  vision 
through  the  viewing  tube  is  clouded,  due  to  sediment  or  blood  from  the 
bladder,  a  small  amount  of  solution  is  allowed  to  run  through,  in  order  to 
clear  the  tube.  The  bladder  may  now  be  routinely  examined,  beginning  with 
the  fundus,  then  the  two  sides,  and  finally  the  trigone.     The  line  of  junction 


544  SURGERY  OF  THE  GENITO-URINARY  TRACT 

between  the  trigone  and  bladder  mneosa  proper  is  usually  clearly  seen,  and 
by  pointing  the  cystoscope  to  this  line  and  following  it  as  far  as  it  goes  to  the 
right,  the  right  ureteral  orifice  is  found.  In  the  same  way  the  left  ureter  is 
found.  Occasionally  the  ureters  cannot  be  found  because  of  the  general 
ruggedness  of  the  bladder,  due  to  a  chronic  cystitis  or  to  tuberculosis.  Both 
openings  are  described  and  the  flow  of  urine  from  them  observed.  If  no 
more  is  to  be  done,  the  fluid  is  allowed  to  escape  and  the  cystoscope  slowly 
removed  while  the  urethra  is  carefully  examined  throughout  its  entire  extent. 
A  soft  rubber  catheter  is  reinserted  and  one-half  ounce  of  5  per  cent,  argyrol 
solution  instilled.  The  catheter  is  then  removed.  It  is  a  good  plan  to  give  5 
grains  of  quinine  by  mouth  at  this  time  in  order  to  prevent  a  possible  instru- 
mental chill. 

Catheterization.  In  order  to  catheterize  the  ureters,  the  cystoscope  is 
passed  as  above  described  and  the  ureteral  openings  found  and  examined  for 
spurts  of  urine.  The  window  is  then  removed  and  the  double  catheterizing 
tube  inserted.  Through  the  small  tubes  are  inserted  two  No.  5  bismuth 
impregnated  ureteral  catheters.  The  catheter  is  then  pointed  upward  and 
outward  and  passed  through  the  ureteral  orifice.  Under  constant  observation 
the  catheter  is  inserted  as  far  as  it  will  go.  As  soon  as  the  least  resistance 
is  encountered  to  the  passage  of  the  catheter,  great  care  should  be  used  in 
order  not  to  perforate  the  ureter  or  pelvis  of  the  kidney.  Undue  force  should 
never  be  used  to  insert  the  catheter.  Often  it  can  be  felt  that  the  catheter 
passes  a  definite  partial  obstruction,  which  distance  is  measured  on  the 
catheter.  Such  obstruction  may  be  a  stone  or  kink  in  the  ureter.  The  other 
ureter  is  then  catheterized  in  the  same  way  and  the  cystoscope  withdrawn, 
the  two  catheters  being  left  in  position  after  leaving  some  mark  on  the  distal 
end  of  one  catheter  to  distinguish  right  from  left.  The  urine  may  now  be 
collected  from  the  separate  kidneys  and  the  catheters  withdrawn  by  gentle 
traction.  Or,  a  radiograph  may  be  taken  with  the  catheters  in  position, 
after  which  they  may  be  removed  in  the  manner  just  described.  Stones  may 
sometimes  be  removed  from  the  ureter  by  injecting  and  dilating  the  ureter 
below  the  obstruction  with  glycerine  throuch  a  ureteral  catheter.  A  stone 
that  has  become  lodged  at  the  ureteral  orifice  can  usually  be  removed  by 
means  of  a  forcep  introduced  through  the  cystoscope. 

Fulffuration.  Papillomata  of  the  urinary  bladder  are  more  frequent  than 
was  formerlv  supposed,  and  often  produce  distressing  symptoms.  The  ideal 
treatment  of  these  benign  tumors  is  by  cautery  with  the  fulgurating  current. 
This  is  a  special  form  of  high  frequency  current  which  allows  of  a  hot  spark 
to  pass  from  a  metal  conductor  through  a  fluid,  such  as  salt  solution,  to  a 
portion  of  tissue.  The  patient  is  made  a  conductor  of  the  current  by  attach- 
ing one  pole  of  the  fulgurator  bv  a  wire  to  a  tin  plate  placed  between  the 
table  and  buttocks.  The  other  pole  is  attached  by  a  wire  to  an  insulated  wire 
passing  through  the  catheterizing  tube  of  the  cystoscope.  A  portion  one  mm. 
in  length,  of  the  end  of  the  latter  wire  is  laid  bare  and  approximated  to  the 
tumor.  The  current  is  controlled  preferably  with  a  foot  switch.  As  the 
tissues  are  cauterized  they  become  white,  and  usually  the  greater  part,  if  not 
all  of  the  mass,  can  be  eliminated  at  one  time.  Otherwise,  the  procedure  can 
be  repeated  in  ten  days,  being  certain  that  the  entire  base  is  thoroughly 
cauterized.  This  is  the  most  satisfactory  cure  of  benign  papillomata  that  we 
know  of,  and  some  of  our  cases  have  remained  well  during  four  years. 

INFECTION  OF  THE  KIDNEY 

Typical  history.  The  patient,  a  mnrried  -woman  thirty  years  of  asre,  gives  the  following 
historv  In  eood  health  as  a  child.  Began  to  menstruate  at  fourteen:  resrular;  painless. 
Married   at  twenty-two.     Two   pregnancies;    labors   normal.      Second   child   four   years    ago. 


SURGERY  OF  THE  GENITO-URINARY  TRACT  545 

Has  never  felt  well  since.  She  had  difficulty  in  emptying  the  bladder  after  the  child-birth. 
On  the  eighth  day  after  confinement  she  was  taken  with  severe  pain  in  right  side  of  the 
abdomen,  which  lasted  for  about  three  months.  Since  then  has  had  numerous  attacks  of  pain 
in  the  same  region,  with  intervals  varying  from  one  week  to  two  months.  Attacks  vary  in 
severity.  Has  often  been  confined  to  bed,  and  the  attacks  have  been  accompanied  by  fever 
and  vomiting.  The  attack  lasts  from  a  few  hours  to  three  days.  The  patient  is  often  jaun- 
diced during  these  periods.  About  four  weeks  ago  this  patient  was  taken  with  pain  in  the 
right  side,  accompanied  by  a  severe  bearing-down  sensation.  At  this  time  she  noticed  a 
mass  in  the  right  side  of  abdomen  the  size  of  an  orange.  Has  had  no  vomiting  and  does 
not  think  she  has  had  much  temperature  with  this  attack.  The  pain  has  been  almost  constant 
up  to  tlie  present  time,  but  the  tumor  has  decreased  somewhat  in  size. 

Present  condition.  Greatly  emaciated,  appetite  good,  heart  and  lungs  normal.  Abdomen 
scaphoid.  A  fluctuating  mass,  somewhat  tense,  extends  from  the  right  costal  arch  to  a  little 
below  the  umbilicus  inward  to  the  median  line.  It  is  plainly  palpable  on  bimanual  examina- 
tion with  one  hand  in  the  lumbar  region  and  one  on  the  abdomen.  It  is  quite  tender  and 
seems  to  move  slightly  on  deep  inspiration.  The  perineum  is  slightly  lacerated;  cervix  also 
slightly  torn.  The  cervix  is  long  and  hard.  The  uterus  far  down  in  pelvis,  normal  position, 
forniees  empty,  adnexa  apparently  nof  connected  with  mass  above. 

During  the  paroxysms  or  period  of  illness  there  is  always  an  increase  in  the  size  of  the 
swelling  and  a  decrease  in  the  flow  of  urine,  but  the  latter  is  less  turbid  at  such  times.  Asi 
the  flow  increases  and  becomes  more  turbid  the  patient's  condition  improves  and  the  swelling 
decreases  in  size. 

The  heart  and  lungs  are  normal.  The  urine  contains  a  considerable  amount  of  pus  but 
is  otherwise  normal.  Upon  examining  the  urine  from  the  two  kidneys  separately,  by  means 
of  the  Harris  segregator,  it  is  found  that  the  fluid  secured  from  the  left  ureter  is  normal, 
while  tlsat  from  the  right  kidney  contains  pus.  The  microscopic  examination  of  the  urine  has 
failed  to  demonstrate  the  presence  of  tubercle  bacilli. 

Diagnosis.  The  swelling  is  located  in  the  vicinity  of  the  right  kidney  and 
the  ascending  colon.  Frequently  an  appendix  is  located  as  high  np  and  some- 
times a  gall  bladder  is  located  as  low  down.  The  presence  of  jaundice  and 
the  persistent  gastric  disturbances  might  indicate  an  empyema  of  the  gall 
bladder,  or  gall  stones.  The  same  conditions  frequently  occur  in  the  case 
of  a  chronic  retro-cecal  appendicitis.  A  tuberculosis  of  the  ascending  colon 
with  adhesions  between  the  omentum  and  transverse  colon  might  cause  the 
same  symptoms.  The  two  elements,  however,  which  seem  to  establish  the 
diagnosis  are :  1.  The  fact  that  there  is  pus  in  the  urine  coming  from  the 
right  kidney,  and,  2.  The  fact  that  the  condition  is  evidently  the  result  of  a 
puerperal  infection  which  first  affected  the  bladder  and  then  the  ureter,  and, 
by  way  of  an  ascending  infection,  the  kidney.  This  is  still  further  confirmed 
by  the  regular  variations  in  the  size  of  the  swelling  and  by  the  synchronous 
changes  in  the  character  of  the  urine.  The  patient  lived  in  a  small  town  in 
the  mining  regions  at  the  time  of  her  confinement,  where  she  could  not  obtain 
medical  care  and  good  nursing ;  hence  it  is  likely  that  there  remained  residual 
urine  in  the  bladder  for  a  considerable  time  and  that  the  pelvis  of  the  kidney 
was  greatly  dilated  by  the  return  pressure.  The  infection  of  the  pelvis  of  the 
kidney  probably  occurred  on  the  eighth  day  after  confinement,  when  the 
patient  suffered  the  severe  pain. 

So  long  as  there  was  fairly  good  drainage  from  the  distended  pelvis  of 
the  kidney  through  the  ureter,  there  were  no  serious  symptoms,  because  there 
was  but  a  slight  amount  of  absorption,  the  pus  being  diluted  with  urine  con- 
stantly secreted.  But  as  soon  as  the  ureter  became  temporarily  blocked  by 
an  accumulation  of  thick  pus,  or  on  account  of  edema,  the  confined  urine 
became  more  septic  and  absorption  more  extensive.  The  increased  pressure 
increases  the  pain,  and  the  absorption  increases  the  temperature.  The  gastric 
disturbance  can  be  accounted  for  by  the  same  conditions.  Jaundice  frequently 
accompanies  abscesses  of  the  kidney  or  the  appendix,  without  direct  involve- 
ment of  the  liver  or  the  biliary  tract,  although  these  parts  are  frequently 
involved  secondarily.  The  most  important  point  in  determining  the  differ- 
ential diagnosis,  however,  is  the  demonstration  of  pus  in  the  urine  from  the 
right  kidney,  and  normal  urine  from  the  left.    "We  can  consequently  make  a 

35 


)46 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


I  I 

I  \ 


r  / 


^" 


Atrophy  of  Kidney  Structure  with  the  Formation  of  a  Large  Cyst.    Dilatation  of  th? 

Ureter  from  Obstruction, 


SURGERY  OF  THE  GENITO-URINARY  TRACT  547 

positive  diagnosis  of  pus  in  the  pelvis  of  the  right  kidney  without  being  able 
to  positively  exclude  the  presence  of  disease  in  the  vermiform  appendix,  the 
gall  bladder  and  biliary  ducts. 

The  disease  has  existed  for  four  years  and  the  history  of  the  case  shows 
that  the  infection  has  probably  extended  upward  through  the  ureter  from 
the  bladder.  It  is  difficult  to  determine  in  any  given  case  Avhat  secondary 
conditions  may  have  resulted  in  this  period  of  time.  The  fact  that  aside  from 
the  presence  of  pus  the  urine  is  nearly  normal  Avould  indicate  that  no  great 
amount  of  destruction  of  kidney  tissue  had  occurred,  but  that  the  disease  is 
chiefly  confined  to  the  pelvis  of  the  kidney. 

Obstruction  to  the  flow  of  pus  and  urine  from  the  right  kidney  during 
periods  of  exacerbation  of  the  disease  might  indicate  an  obstruction  of  the 
ureter  due  to  the  presence  of  a  renal  calculus,  which  could  readily  have 
formed  with  the  conditions  present  in  this  case,  or  an  occlusion  due  to  the 
presence  of  thickened  pus  or  to  an  edema,  or  to  an  acute  bend  in  the  ureter, 
or  through  the  presence  of  an  abnormally  placed  blood  vessel  compressing 
the  ureter.  In  case  the  obstruction  is  due  to  a  calculus  the  relief  which 
occurs  when  the  calculus  is  displaced  is  usually  much  more  sudden  and  more 
complete  than  it  was  in  this  case.  Obstruction  from  an  acute  bend  of  the 
ureter  occurs  only  in  cases  in  which  the  kidney  is  abnormally  movable,  which 
is  not  evident  in  this  patient.  However,  so  far  as  the  treatment  and  the 
prognosis  are  concerned,  it  is  immaterial  to  the  patient  whether  this  part  of 
the  diagnosis  be  made  before  or  during  the  operation. 

Indications  for  operation.  It  is  plain  that  unless  this  patient  obtains  relief 
from  her  present  condition  she  will  continue  in  her  downward  course,  which 
has  become  more  and  more  marked  as  time  has  progressed  during  the  past  four 
years.  The  constant  absorption  of  pus  will  not  only  continue  to  jeopardize  her 
nutrition  by  interfering  with  her  appetite  and  her  digestion  indirectly,  but  it 
will  undoubtedly  result  in  amyloid  degeneration,  especially  of  the  kidneys  and 
the  liver.  The  constant  presence  of  pus  in  the  bladder  is  likely  to  result  in  an 
infection  of  the  pelvis  of  the  left  kidney,  which  has  as  yet  escaped.  Sooner  or 
later,  the  tissues  of  the  kidney  itself  will  become  inflamed,  and  then  only  the 
left  kidney  will  remain  to  perform  the  labor  of  both  organs.  Aside  from  this 
there  is  always  the  danger  of  metastatic  infection  of  other  parts  of  the  body 
from  the  presence  of  this  accumulation  of  pus,  either  by  extension  or  by  metas- 
tasis, because  this  is  possible  in  case  of  an  accumulation  of  pus  in  any  part  of 
the  body  if  the  drainage  is  not  perfect.  The  only  way  in  which  relief  can  be 
obtained  is  by  direct  drainage  by  means  of  a  free  incision. 

Preparation  for  operation.  In  order  to  insure  against  an  accident  occurring 
rather  frequently  after  operations  upon  the  kidney- — which  consists  in  a  com- 
plete absence  in  the  secretion  of  urine  by  both  kidneys  and  consequent  uremia 
— it  is  wise  to  provide  for  very  free  elimination  before,  the  operation  is  per- 
formed, first,  by  the  administration  of  cathartics,  and,  second,  by  having  the 
patient  drink  great  quantities  of  distilled  water,  preferably  hot.  In  the  mean- 
time the  patient  is  placed  for  a  week  upon  a  simple  milk  diet. 

In  order  to  increase  the  activity  of  the  glands  of  the  skin,  she  will  receive 
warm  baths  daily.  On  the  day  before  the  operation  two  ounces  of  castor  oil 
will  be  given  as  usual.  In  this  way  it  is  possible  to  place  the  patient's  kidneys 
in  a  fairly  safe  condition  even  where  there  has  been  much  impairment  of  their 
function. 

Technique.  The  operation  must  primarily  be  exploratory,  because  the  state 
of  the  kidney  must  determine  the  course  to  be  employed.  If  the  condition  of 
the  kidney  is  such  as  to  preclude  the  possibility  of  its  restoration  to  normal, 
as  a  result  of  a  conservative  operation,  then  its  removal  is  indicated,  because 
the  examination  with  the  Harris  segregator  has  demonstrated  the  fact  that  the 


548  SURGERY  OF  THE  GENITO-URINARY  TRACT 

left  kidney  is  normal.  On  the  other  hand,  if  it  is  possible  to  preserve  the  kid- 
ney this  must  by  all  means  be  done.  AVere  the  other  kidney  not  normal,  it 
would  not  be  wise  to  remove  the  diseased  one,  so  long  as  any  portion  of  it 
remains  capable  of  excreting  urine,  even  though  it  might  not  be  possible  to 
obtain  a  perfectly  normal  kidney  as  a  result  of  the  operation,  because  a  patient 
can  live  longer  with  two  impaired  kidneys  than  with  one. 

Were  this  patient  suffering  from  a  tuberculosis  of  this  kidney  our  position 
would  be  quite  the  reverse,  because  then  we  would  remove  this  kidney  even 
though  it  might  not  be  seriously  diseased,  as  if  a  tuberculous  kidney  is  simply 
drained  the  other  kidney  is  almost  certain  to  become  involved,  while  if  it  is 
removed  the  physiologic  increase  in  the  circulation  of  the  second  kidney  seems 
to  overcome  a  slight  amount  of  tuberculosis  after  the  first  kidney  has  been 
removed. 

Beginning  at  a  point  near  the  twelfth  rib  an  incision  is  carried  downward 
towards  the  crest  of  the  ilium  through  the  edge  of  the  erector  spina  and  quad- 
ratus  lumborum  muscles,  being  careful  to  distinguish  the  ilio-hypogastric 
nerve  and  to  retract  it  forward  in  order  to  avoid  injuring  it.  It  is  well  to 
make  a  free  incision  in  order  to  expose  the  kidney  well  for  palpation  and 
inspection.  This  exposes  the  fat  capsule  of  the  kidney.  "Were  we  not  prac- 
tically certain  of  the  presence  of  pus  in  this  kidney,  the  condition  of  the  vermi- 
form appendix  and  the  gall  bladder  could  be  determined  Avith  ease  and  safety 
by  perforating  the  peritoneum  in  front  of  the  ascending  colon  and  making  a 
digital  examination  of  these  organs. 

The  appendix  can  readily  be  removed  through  this  incision,  unless  it  is  too 
extensively  adherent,  and  it  is  also  possible  to  remove  gall  stones  from  the  gall 
bladder  through  the  same  incision,  although  the  incision  which  has  been 
described  before  is  much  to  be  preferred. 

In  this  case,  however,  opening  of  the  peritoneum  would  not  be  proper,  as 
it  would  increase  the  likelihood  of  an  infection  of  the  peritoneal. cavity. 

The  fat  capsule  is  opened  and  a  dark,  oblong  organ  is  seen  in  the  wound. 
Grasping  this  between  the  fingers  it  is  found  to  fluctuate.  This  is  undoubtedly 
due  to  the  presence  of  pus  in  the  dilated  pelvic  cavity.  An  incision  two  inches 
in  length  is  made  through  the  cortex  of  the  kidney  a  little  behind  the  center  of 
its  convex  surface,  which  is  the  least  vascular  portion  of  the  organ.  Imme- 
diately there  is  a  free  flow  of  pus  diluted  with  urine.  The  finger  is  inserted 
into  the  pelvis  of  the  kidney  and  this  cavity  is  carefully  palpated,  each  calix 
being  explored  with  the  finger,  in  order  to  determine  the  presence  of  a  renal 
calculus.  The  entire  pelvis  is  lined  with  granulation  tissue  and  there  is  a 
considerable  amount  of  thickening  of  the  tissues  of  the  pelvis.  The  cortex  of 
the  kidney  is  thin  and  somewhat  congested,  but  otherwise  normal.  A  large 
probe  with  a  bulbous  end  is  introduced  into  the  ureter  and  this  is  found  free 
from  obstruction  by  a  stone. 

A  catheter  is  now  introduced  into  the  bladder  through  the  urethra  and  held 
closed,  then  a  small  catheter  is  introduced  into  the  ureter  through  the  kidney. 
The  urine  is  permitted  to  fiow  from  the  catheter  in  the  bladder  and  simulta- 
neously a  one-half  per  cent,  solution  of  methyl  blue  is  injected  into  the  other 
catheter.  At  once  the  urine  takes  a  blue  color  showing  that  at  the  present 
time  the  ureter  is  open. 

It  seems  likely  that  drainage  of  the  kidney  would  result  in  restoration  to  a 
fairly  normal  condition,  and  that  the  kidnej^  will  ultimately  become  nearly  as 
useful  as  its  fellow. 

In  order  to  stimulate  the  healing  of  the  pelvic  cavity,  and  at  the  same  time 
establish  .free  drainage,  the  pelvis  will  be  tamponed  carefully  with  iodoform 
gauze.  A  rubber  drainage  tube  will  also  be  inserted  into  this  cavity,  the  gauze 
being  tamponed  around  this.    The  drainage  tube  and  gauze  are  carried  out 


SURGERY  OF  THE  GENITO-URINARY  TRACT  549 

through  the  wound  and  the  latter  is  sutured  above  and  below  it.  A  large 
dressing  applied  to  the  surface  completes  the  operation. 

In  case  a  kidney  has  been  split  longitudinally,  as  in  this  case,  and  the  pelvis 
has  been  found  to  be  in  an  aseptic  condition,  which  is  not  infrequently  true  in 
cases  in  which  a  uric  acid  or  an  oxalate  of  calcium  calculus  is  found,  it  may  be 
unnecessary  to  tampon  the  pelvis  of  the  kidney  with  gauze.  In  these  cases  it 
is  well  to  insert  a  Jacob 's  retention  catheter  into  the  lower  end  of  the  wound 
and  to  suture  the  remaining  portion  of  the  wound  with  catgut  sutures  passed 
through  layers  of  iodoform  gauze  placed  upon  the  flat  surface  of  the  kidney  on 
either  side  to  prevent  the  sutures  from  cutting. 

After-treatment.  Occasionally  a  hemorrhage  occurs  upon  removing  the 
tampon  which  has  been  placed  in  the  kidney,  because  the  blood  vessels  in  this 
organ  are  characterized  by  especially  thin  walls,  making  their  closure  very 
unstable.  On  this  account  it  is  wise  to  postpone  withdrawing  the  tampon  until 
it  has  been  loosened  by  the  development  of  granulations.  It  may  be  removed 
a  little  at  a  time  until  it  has  all  been  loosened.  In  the  meantime  the  urine 
drains  through  the  wound  and  the  mucous  membrane  lining  the  ureter  has  an 
opportunity  to  become  normal,  because  the  fiow  of  pus  and  urine  through  this 
canal  no  longer  causes  an  irritation. 

In  cases  like  the  one  instanced  the  urine  usually  becomes  clear  in  a  few 
days,  as  the  drainage  through  the  wound  is  so  free  that  there  is  no  accumula- 
tion. The  pelvis  of  the  kidney,  Avhich  has  been  dilated  for  a  long  period  of 
time,  becomes  contracted  for  the  same  reason,  and  all  of  the  conditions  become 
more  nearly  normal  in  a  comparatively  short  period.  It  is  wise  to  continue  the 
drainage  until  there  is  no  doubt  but  that  the  pelvis  of  the  kidney  and  the 
ureter  are  nearly  normal,  so  that  natural  drainage  will  be  established. 

Use  of  distilled  water.  The  patient  should  receive  an  abundance  of  dis- 
tilled water  at  intervals  of  one  to  two  hours  regularly,  in  order  to  dilute  the 
urine,  which  will  form  a  non-irritating  fluid  as  it  passes  over  the  diseased 
surfaces.  In  pyelitis,  and  in  fact  in  other  conditions,  such  as  renal  calculi,  in 
which  the  pelvis  of  the  kidney  is  diseased,  distilled  water  given  internally  in 
considerable  quantities  is  a  most  useful  remedy.  Many  patients  who  have 
suffered  for  years  from  renal  colic  are  permanently  and  perfectly  relieved  by 
this  simple  means.  It  seems  necessary  for  the  urine  to  possess  a  certain  concen- 
tration in  order  to  make  the  formation  of  renal  or  cystic  calculi  possible  in  the 
absence  of  foreign  bodies,  which  may  account  for  the  clinical  fact  that  has 
just  been  mentioned.  The  free  use  of  distilled  water  results  in  diluting  the 
urine  to  such  an  extent  that  renal  calculi  or  renal  sand  no  longer  form.  jMore- 
over,  the  urine  becomes  exceedingly  bland  and  non-irritating,  and  we  have 
frequently  observed  not  only  a  relative  decrease  of  the  pus  in  the  urine  from 
dilution,  but  also  an  absolute  decrease,  as  a  result  of  drinking  distilled  water 
freely. 

The  formation  of  a  fistula.  In  case  the  ureter  does  not  become  normal  in 
a  relatively  short  time,  which  m-ay  occur,  especially  Avhere  the  disease  has 
existed  for  a  long  period,  the  wound  in  the  kidney  will  not  heal,  and  a  fistula 
may  persist,  which  is  not  only  disagreeable  because  the  dressings  are  con- 
stantly wet,  but  which  results  in  an  excoriation  of  the  skin  on  account  of  the 
irritating  effect  of  the  urine  with  which  it  is  constantly  in  contact.  In  these 
cases,  it  is  advisable  to  introduce  a  soft  rubber. retention  catheter  with  a  bul- 
bous end,  preferably, — described  elsewhere  in  this  volume  as  a  Jacob's 
catheter, — into  the  kidney  and  to  weight  the  free  end  by  inserting  a  glass  tube 
into  it  and  then  placing  this  in  a  bottle,  which  ma}^  be  carried  underneath  the 
clothing,  suspended  from  a  belt.  At  night  a  longer  rubber  tube  is  attached  to 
the  catheter  and  its  free  end  is  passed  out  into  a  vessel  outside  the  bed  on  the 
floor.    This  tube  will  act  as  a  siphon  and  the  patient  will  remain  entirely  dry. 


550  SURGERY  OF  THE  GENITO-URINARY  TRACT 

Occasionally  the  ureter  does  not  recover,  and  then  it  will  become  necessary 
either  to  remove  the  kidney  or  to  be  satisfied  with  the  drainage  which  has  been 
established,  together  with  all  of  the  resulting  inconveniences. 

The  quantity  and  quality  of  urine  secreted  by  the  diseased  kidney  can  now 
be  easily  determined,  and  it  will  be  apparent  from  this  whether  the  kidney 
should  be  saved.  So  long  as  the  opening  into  the  kidney  is  too  large  for  the 
use  of  a  retention  catheter,  the  quantity  of  urine  can  be  determined  by  weigh- 
ing the  dressings  before  they  are  applied  and  after  thej'  have  been  in  place  for 
a  given  time. 

Response  of  the  remaining  kidney,  it  is,  however,  not  safe  to  judge  of  the 
condition  of  the  remaining  kidney  by  the  amount  of  urine  secreted  into  the 
bladder  from  it,  while  all  of  the  urine  is  siphoned  out  through  the  catheter  in 
the  diseased  kidnej'.  In  one  instance  of  this  kind  in  which  we  removed  the 
diseased  kidney  notwithstanding  the  fact  that  but  180  cc.  of  urine  was  secreted 
from  the  other  kidney  the  latter  at  once  became  more  active,  secreting  400  cc. 
on  the  third  day  after  the  removal,  then  advancing  slowly  until  2,000  cc.  were 
secreted  daily  within  three  weeks,  then  very  gradually  reducing  to  1,500  cc. 
when  the  normal  amount  of  liquid  nourishment  and  water  was  taken.  The 
case  was  one  in  which  the  uterus  had  been  removed  for  carcinoma  in  a  very 
weak,  emaciated  patient.  The  lower  end  of  the  right  ureter  being  involved  it 
was  excised  Avitli  the  cautery.  For  several  days  both  kidneys  secreted  a  nor- 
mal amount  of  urine,  one  secreting  into  the  vagina,  the  other  into  the  bladder. 
Then  the  one  secreting  into  the  bladder  produced  less  and  less,  running  as  low 
as  100  cc.  on  some  days.  The  patient's  condition  became  worse  constantly.  At 
the  end  of  six  weeks  she  seemed  in  a  hopeless  state,  when  she  developed  a 
pyelitis  and  we  were  forced  to  choose  between  certainly  losing  her  from  the 
pyelitis  with  uremia  and  losing  her  most  likely  from  shock  and  uremia  after  a 
nephrectomy. 

The  fact  that  the  left  kidney  had  secreted  normal  urine  directly  after  the 
hysterectomj'  determined  us  to  make  a  very  rapid  nephrectomy,  with  the  result 
stated  above.  It  is  consequently  not  proper  to  judge  entirely  by  the  quantity 
the  other  kidney  secretes  under  these  conditions  as  regards  its  ability  after  the 
removal  of  the  diseased  kidney. 

We  have  also  been  able  to  confirm  the  observation  of  others  in  cases  of 
tuberculosis  of  the  kidney,  that  the  removal  of  one  kidney  would  result  in  the 
secretion  of  more  urine,  and  urine  of  a  better  quality,  by  the  remaining  kidney 
than  was  secreted  by  both  before  the  nephrectomy  was  made. 

In  case  of  intermittent  hydronephrosis,  whether  the  urine  be  clear  or  mixed 
with  pus,  it  is  always  important  when  the  kidney  is  first  exposed  to  determine 
the  character  of  the  obstruction.  If  this  is  due  entirely  to  a  kinking  of  the 
ureter  from  a  dropping  down  of  the  kidney  and  the  ureter  is  not  equally  mobile 
with  the  kidney,  simply  dividing  the  adhesions  holding  the  ureter  and  fasten- 
ing the  kidney  in  place  by  nephrorrhaphy,  as  described  elsewhere,  will  suffice. 
If  the  ureter  is  bent  acutely  over  an  aberrent  blood  vessel  the  latter  should  be 
caught  between  two  pairs  of  forceps,  cut  and  ligated,  and  nephrorrhaphy 
should  again  be  performed.  If  the  obstruction  is  due  to  a  deformity  of  the 
pelvis  itself  then  a  plastic  operation  should  be  attempted,  as  originally  recom- 
mended by  Fenger.  The  method  developed  by  IMayo,  as  illustrated  in  accom- 
panying plates,  is  so  satisfactory  that  we  give  it  in  full  later  on. 

PERINEPHRITIC  ABSCESS 

"While  this  condition  most  commonly  results  from  stone,  tuberculosis  and 
pyonephrosis,  it  occasionally  follows  such  seemingly  slight  infections  as  fur- 
uncles and  felons.  The  abscesses  follow  small,  metastatic  infections  in  the 
kidney  cortex,  which  rupture  externally  and  infect  the  perinephritic  fat. 


SURGERY  OF  THE  GENITO-URINARY  TRACT  551 

When  this  occurs  as  a  metastatic  infection,  the  symptoms  come  on  very 
suddenly  and  without  any  previous  indications  of  renal  trouble.  The  pain  in 
the  kidney  region  is  intense  but  not  of  the  colicky  nature  of  renal  colic.  There 
is  a  marked  tenderness  in  the  renal  triangle  and  rather  early  signs  of  edema 
in  the  lumbar  region  of  the  affected  side.  The  urine  is  very  apt  to  be  negative, 
because  unless  the  metastatic  abscess  ruptures  into  the  pelvis  of  the  kidney 
there  will  be  no  sign  of  pus  in  the  urine.  The  temperature  usually  ranges 
from  102°  to  104°,  and  an  unusually  high  leucocytosis  is  found.  Miller,  of 
Philadelphia,  places  the  average  leucocyte  count  in  perinephritic  abscess  at 
about  25,000. 

The  above  symptoms,  with  the  presence  of  a  tender  mass  in  the  iliocostal 
space,  renders  the  diagnosis  quite  clear. 

The  treatment  should  be  instituted  early  and  consist  in  simply  making  an 
incision  over  the  kidney  area  and  draining  the  abscess.  These  cases  usually 
clear  rapidly  after  simple  drainage  and  make  a  complete  recovery. 

TUBERCULOSIS  OF  THE  KIDNEY 

The  frequency  of  tuberculosis  of  the  kidney  seems  to  be  on  the  increase,  but 
this  is  undoubtedly  due  to  the  fact  that  the  disease  is  being  recognized  more 
often  in  its  earlier  stages.  Kroenlein  has  recently  shown  that  nearly  thirty 
per  cent,  of  all  surgical  conditions  of  the  kidney  are  tuberculous  in  origin. 

The  general  opinion  among  surgeons  seems  to  be  that  renal  tuberculosis  is 
usually  unilateral  in  the  beginning,  and  that  if  the  diagnosis  is  made  early 
extremely  few  cases  of  bilateral  renal  tuberculosis  would  be  encountered.  The 
physician  is  not  always  responsible  for  a  late  diagnosis  because  in  many  of 
these  cases  the  symptoms  are  so  slight  that  the  patient  does  not  consult  a  doctor 
until  the  disease  is  far-advanced  in  the  kidney,  or  has  invaded  the  ureter  or 
bladder. 

The  most  frequent  among  the  early  symptoms  is  hematuria  which  may 
occur  without  the  accompaniment  of  pain.  Polyuria  is  practically  always 
present  and  remains  constant.  Pyuria  and  albumin  are  often  present  early  but 
are  apt  to  be  intermittent.  Reflex  s^'mptoms  are  quite  pronounced,  such  as 
frequent  urinations  accompanied  by  burning  sensations.  Frequently  all  the 
symptoms  are  referred  to  the  bladder  and  the  physician  may  be  misled  into 
thinking  the  whole  trouble  is  vesical  in  origin.  Pain  and  tenesmus  are  not 
apt  to  be  marked  unless  there  is  a  high  grade  of  inflammation  present  in  the 
region  of  the  trigone.  The  frequency  of  urination  is  present  both  day  and 
night,  and  the  burning  on  urination  is  constant.  Colicky  pain  is  rather  rare 
but  there  is  usually  present  a  dull,  aching  pain  in  the  loin.  The  temperature 
usually  takes  about  the  same  course  as  in  an  early  case  of  pulmonary  tubercu- 
losis. Tubercle  bacilli  are  usually  not  found  in  the  urine  until  after  the 
appearance  of  pus  therein.  The  use  of  the  cystoscope  and  catheterization  of 
the  ureters,  combined  with  radiography,  is  of  great  importance  in  the  diag- 
nosis of  renal  tuberculosis. 

If  the  diagnosis  is  made  before  both  kidneys  are  involved,  the  plan  of 
treatment  is  very  clear,  which  is  early  removal  of  the  affected  kidney. 

The  operation  of  nephrectomy,  as  described  below,  should  be  carried  out  in 
these  cases,  but  should  embody  the  following  points :  removal  of  the  ureter  as 
low  down  as  possible  and  a  thorough  cauterization  of  the  stump,  and  as  com- 
plete a  removal  of  the  fatty  capsule  as  feasible.  The  wound  should  be  closed 
carefully  without  drainage,  unless  it  seems  probable  that  the  parts  have  been 
contaminated  at  the  time  of  operation. 


552 


SURGERY  OF  THE  GENITO-URINARY  TRACT 
NEPHRECTOMY 


When  we  find  the  kidney  hopelessly  destroyed  by  infection,  or  from  a 
malignant  growth  of  the  organ,  a  nephrectomy^  can  be  done  through  the  same 
incision  that  we  use  for  a  nephrotomy.     In  case  a  diagnosis  of  a  malignant 


^' 


^-  -v^  :«i 


fj — Uvertev 
Arxoni^lous  Blood-vessels., 

Hydronephrosis  from  Kinking  Ureter  Caused  by  Anomalous  Blood  Vessels.     (Mayo.) 

growth  is  made  before  the  operation  is  begun,  we  prefer  the  anterior  incision 
along  the  outer  edge  of  the  rectus  abdominis  muscle.  The  incision  may  be 
prolonged  sufficiently  to  remove  a  kidney  under  any  condition  without  the 
necessity  of  pulling  upon  the  tissues.  In  difficult  cases  the  posterior  incision 
is  not  sufficiently  long,  even  though  it  be  extended  from  the  ribs  to  the  ilium. 
Aside  from  the  incision  the  steps  of  the  operation  are  the  same.  The  kidney  is 
carefully  loosened  from  the  fat  capsule  in  non-malignant  cases.    Then  a  pair 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


553 


of  clamp  forceps  are  applied  to  the  vessels  entering  the  kidney.  These  forceps 
should  be  perfectly  reliable,  but  should  not  be  sharp  at  any  point,  in  order 
not  to  injure  the  vessels.     The  renal  veins  are  thin-walled  and  easily  injured, 


f. 


Blood  Vessels  (>ct  and  Tied. 


Fatty  Fasclil  Flap  Eaised  A^^D  Uretero-Peltic  Jcxctuee 
Divided.    (Mayo.; 


consequently  great  care  should  be  exercised  in  loosening  the  kidney.  Drag- 
ging upon  the  renal  vessels  is  dangerous,  for  the  veins  might  easily  be  torn. 
This  accident  is  somewhat  more  likely  in  removing  the  left  kidney  because  of 
the  anatomical  peculiarity  of  the  right  renal  A^ein.  After  the  forceps  have  been 
applied  the  kidney  is  cut  away  by  severing  the  vessels  just  as  they  enter  the 


554 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


pelvis.  The  vessels  wliicli  project  beyond  the  forceps  are  now  picked  up  sepa- 
rately, ligated  with  catgut,  then  a  general  ligature  of  catgut  is  passed  about 
the  entire  pedicle.    As  this  ligature  is  tightened  the  forceps  are  loosened  so  as 


Plastic  Operation  on  Uretero-Pelvic  Juncture  Completed.     (Mayo.) 


to  permit  the  ligature  to  compress  the  vessels  in  the  pedicle  to  the  fullest 
extent.  In  this  way  each  vessel  is  ligated  twice,  which  eliminates  the  danger 
to  the  patient  from  the  slipping  of  a  ligature.  It  is  important  to  apply  the 
ligature  sloAvly  and  carefully  because  it  may  cut  the  wall  of  the  vein  and  cause 
a  fatal  hemorrhage. 


SURGERY  OF  THE  GENITO-URINARY  TRACT  .       555 

If  the  kidney  is  small  the  ligature  may  be  applied  to  the  vessels  composing 
the  pedicle  before  the  kidney  has  been  removed,  without  first  applying  the 
pressure  forceps.  In  other  cases  in  which  it  seems  difficult  to  ligate  the  pedicle 
after  the  pressure  forceps  have  been  applied  this-  may  be  avoided  by  simply 
leaving  the  forceps  in  place  for  twenty-four  hours  and  arranging  the  dressing 
around  this  in  a  manner  to  prevent  pressure  upon  the  handles  of  the  forceps. 
These  forceps  are  loosened  twenty-four  hours  after  the  operation  and  removed 
twelve  hours  later  after  the  stump  has  withdrawn  from  the  bite  of  the  instru- 
ment. 

This  method  has  been  so  much  more  satisfactory^  in  our  practice  than  liga- 
tion of  the  pedicle  that  for  several  years  we  have  used  it  entirely  in  a  large 
number  of  cases,  and  have  never  had  an  unfavorable  effect.  A¥e  use  strong  but 
quite  elastic  forceps,  finely  serrated,  with  perfectly  smooth  ends.  We  always 
apply  two  pairs,  then  cut  the  pedicle  beyond  the  second  pair,  then  remove  the 
pair  farthest  from  the  kidney  and  leave  the  other  in  place  so  that  the  pedicle 
extends  about  one  cm.  beyond  the  grasp  of  these  forceps. 

The  wound  is  sutured  down  to  the  forceps.  In  case  the  stump  has  been 
ligated  it  is  well  to  leave  a  wick  of  iodoform  gauze  in  the  wound  extending 
down  to  the  stump,  which  may  be  removed  in  a  few  days  unless  during  the 
removal  of  the  kidney  the  wound  has  become  infected  with  pus  spilled  from  an 
abscess.  In  this  event  a  tubular  rubber  drain  should  be  added  to  the  gauze 
tampon. 

Both  the  preparatory  and  the  after-treatment  are  the  same  as  in  those  cases 
in  which  nephrotomy  is  performed.  It  happens  occasionally  that  the  other 
kidney,  which  was  fairly  normal  before  the  operation,  secretes  little  or  no  urine 
for  several  days  afterwards.  This,  however,  is  not  so  common  if  elimination 
has  been  favored  before  the  operation  by  the  use  of  milk  diet,  cathartics  and  an 
abundance  of  distilled  water  as  where  this  precaution  has  not  been  taken. 

Relative  anuria  after  operation.  Should  anuria  occur  subcutaneous  trans- 
fusions of  a  quart  of  normal  salt  solution  once  or  twice  a  day,  and  the  use 
of  saline  cathartics  and  steam  baths,  and  continuous  rectal  instillation  of  water 
by  the  drop  method,  are  indicated.  Some  of  these  patients  sufiier  severely 
from  nausea  or  vomiting,  which  is  most  readily  relieved  by  thoroughly  irri- 
gating the  stomach,  through  a  siphon  stomach  tube,  with  normal  salt  solution 
as  hot  as  it  can  be  borne,  up  to  110°  P. 

The  hot  gastric  lavage  alone  is  sometimes  shortly  followed  by  the  free 
secretion  of  urine.  In  other  patients  the  same  results  may  be  obtained  by 
giving  a  warm  enema  of  one-half  pint  of  normal  salt  solution  every  hour, 
introducing  the  fluid  by  the  drop  method. 

From  internal  remedies  we  have  not  seen  much  benefit  in  such  cases,  and 
can  consequently  not  speak  of  them  confidently,  with  the  single  exception 
of  freshly  prepared  infusion  of  digitalis  made  from  reliable  leaves. 

An  enema  of  warm  salt  solution  in  quantity  varying  from  eight  ounces 
to  one  pint,  to  which  from  ten  to  twenty-five  grains  of  sodium  acetate  has 
been  added,  frequently  increases  the  flow  of  urine  in  these  cases  in  which 
there  is  little  or  no  urine  excreted  for  some  hours  after  the  operation.  This 
may  be  administered  every  hour  at  first,  and  less  frequently  later  on. 

The  value  of  gastric  lavage  with  hot  normal  salt  solution  in  cases  in 
which  nausea  exists  is  certainly  very  great,  as  it  removes  a  quantity  of  de- 
composing mucus  from  the  stomach  and  supplies  fluid  for  the  purpose  of 
stimulating  diuresis.  "When  given  as  hot  as  can  be  borne  and  repeated  fre- 
quently the  patient  usually  begins  to  perspire   freely  during  the   adminis- 


556 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


tration  of  the  lavage,  and  this  in  itself  is  of  course  of  great  benefit.  Placing 
a  canvas  tent  over  the  bed  with  the  patient's  head  protruding,  and  filling 
this  tent  with  hot  air  generated  from  a  Bunsen  burner,  is  very  beneficial. 


P/s,'v  'y^'^/^^^^ 


mp>fmL  . 


if^^^^^ 


'.^/fv 


i 


<^'/ 


Fatty  Fascial  Flap  in  Position  and  Held  by  a  Few  Catgut  Sutures.     (Mayo.) 

CYSTIC  KIDNEY 

Occasionally  a  kidney  containing  multiple  cysts  is  encountered.  Were 
these  in  only  one  kidney  a  nephrectomy^  might  be  indicated ;  but  as  it  is  usu- 
ally present  in  both  kidneys  at  the  same  time,  and  as  there  is  consequently 
not  very  much  kidney  substance  left,  it  is  not  wise  to  do  a  nephrectomy  in 
such  cases,  because  the  operation  is  very  likely  to  give  the  patient  no  relief, 
and  usually  hastens  his  death.  It  seems  wiser  to  split  the  true  capsule  of 
the  kidney  throughout  its  length,  to  peel  it  back  on  each  side,  and  cut  it 
away,  and  possibly  to  make  crucial  punctures  of  the  superficial  cysts.  This 
will  relieve  the  tension  upon  the  remaining  kidney  tissue,  it  will  improve 


SURGERY  OF  THE  GENITO-URINARY  TRACT  557 

the  blood-supply  to  the  kidney,  and  will  not  reduce  the  amount  of  kidney 
tissue. 

This  method  has,  however,  not  been  sufficiently  tried  to  have  a  position 
among  recognized  surgical  operations,  and  we  simply  mention  it  here  for 
want  of  a  method  we  can  recommend  from  personal  experience. 

If  the  kidney  contains  but  few  cysts  these  may  be  excised  without  diffi- 
culty and  with  safety  to  the  patient,  the  defect  being  closed  by  one  or  two 
catgut  sutures. 

Treatment  of  congenital  cystic  kidney.  Lund,  of  Boston,  recommends 
very  enthusiastically  the  treatment  suggested  by  Professor  Rovsing,  of  Copen- 
hagen, according  to  which  one  of  the  kidneys  is  exposed  by  a  posterior  inci- 
sion. The  cysts  are  laid  open  and  the  cavity  tamponed  with  gauze  which 
is  left  in  place  for  a  period  of  ten  days.  If  possible  all  of  the  cysts  of  the 
kidney  are  treated  in  this  way;  then  the  kidney  is  replaced  and  drainage 
instituted.  As  soon  as  the  patient  has  regained  a  normal  condition  and  the 
wound  has  completely  healed  the  same  procedure  is  applied  on  the  opposite 
side.     The  results  from  this  operation  have  been  very  satisfactory. 

We  would  suggest  a  form  of  treatment  in  addition  to  this  which  has 
been  most  satisfactory  in  a  number  of  cases  under  our  care.  This  consists 
in  the  administration  of  only  such  articles  of  food  as  require  the  least  amount 
of  wear  and  tear  upon  the  tissues  of  the  kidneys  for  the  amount  of  food  value 
received  by  the  patient.  The  diet  should  consist  largely  of  milk,  cream,  but- 
termilk, cooked  vegetables  and  cooked  fruits.  Meat  and  fresh  fish  should 
be  given  very  sparingly.  Eggs  either  soft-boiled,  poached  or  raw  serve  the 
same  purpose,  so  far  as  the  nutrition  is  concerned,  as  meat,  but  the  wear  and 
tear  upon  the  kidneys  is  very  much  less.  They  can  therefore  be  given  in 
moderate  quantity. 

NEPHRORRHAPHY  FOR  THE  RELIEF  OF  MOVABLE  KIDNEY 

Clinical  case.  The  patient  is  a  married  woman,  twenty-four  years  of  age,  the  mother 
of  two  cliildren,  three  and  five  years  of  age.  She  gives  the  following  history:  Father  died 
of  pulmonary  tuberculosis;  otherwise  the  family  history  is  good.  The  patient's  health  was 
good  until  one  year  ago,  when  she  took  a  mis-step  and  eame  down  very  forcibly  on  one  foot. 
From  that  time  on  she  suffered  from  a  dragging  pain  in  the  right  side  of  her  back,  just  below 
the  last  rib.  This  has  increased  constantly.  In  the  meantime  she  has  also  become  very 
nervous,  and  has  lost  her  former  vigorous  appearance.  She  is  unable  to  do  housework  with- 
out grestly  increasing  her  suffering.  She  locates  her  pain  in  the  region  of  the  right  kidney. 
There  are  no  digestive  disturbances,  no  nausea  or  vomiting,  but  the  patient  suffers  greatly 
from  gHseous  distension  of  the  intestines. 

Present  condition.  The  patient  is  fairly  well  nourished;  her  appetite  is  fair;  the  bowels 
are  regular.  Heart,  lungs  and  urine  are  normal.  The  right  kidney  can  be  palpated  and 
moved  beyond  the  median  line  and  down  opposite  the  anterior  superior  spine  of  the  ilium. 
It  can  be  carried  up  into  its  normal  position,  and  when  it  approaches  this  point  it  slips  into 
place  very  suddenly.  When  it  is  out  of  place  the  space  which  it  should  normally  occupy  is 
found  vacant  upon  bimanual  palpation. 

Diagnosis.  The  same  considerations  as  regards  the  differential  diagnosis 
may  be  applied  to  this  as  to  the  previous  case.  The  only  condition  with  which 
a  movable  kidney  can  be  confounded,  in  a  case  like  the  one  before  us,  is  a 
pedunculated  hydrops  of  the  gall  bladder,  or  a  tongue-shaped  projection  from 
the  right  lobe  of  the  liver,  known  as  Eiedel's  lobe,  or  a  tum.or  in  a  very  mov- 
able cecum  or  ascending  colon.  Once  we  encountered  a  carcinoma  of  the 
pylorus  in  an  extremely  movable  stomach  M^hich  was  mistaken  for  a  floating 
kidney.  Occasionally  a  gall  bladder  occluded  by  a  gall  stone  will  become 
distended  to  the  size  of  the  movable  mass  here  found  without  becoming  ad- 
herent. The  neck  of  the  gall  bladder  will  become  stretched  and  the  latter 
jnay  be  movable  in  every  direction,    It  frequently  falls  into  a  space  in  front 


558  SURGERY  OF  THE  GENITO-URINARY  TRACT 

of  the  left  kidney  and  under  the  edge  of  the  liver,  with  the  same  little  jerky 
motion  that  one  feels  in  replacing  a  movable  kidney.  The  thickness  of  the 
abdominal  wall  will  make  it  impossible  to  observe  the  fluctuation  of  the  fluid 
contained  in  the  gall  bladder,  and  it  may  be  quite  impossible  to  make  a  posi- 
tive difi^erential  diagnosis  between  these  two  conditions  until  the  abdomen 
has  been  opened.  Another  condition  which  is  more  easily  difi^erentiated,  but 
which  occasionally  causes  difficulty,  is  a  tongue-like  projection  downwards 
from  the  right  lobe  of  the  liver,  known  as  Riedel's  lobe  (mentioned  above). 
This  may  be  from  six  to  eight  inches  in  length,  or  even  longer,  and  conse- 
quently its  lower  end  can  be  dislocated  a  considerable  distance.  This  mass  is, 
however,  continuous  with  the  liver,  and  it  is  never  quite  as  movable  as  the 
mass  in  this  case,  and  it  is  always  only  its  lower  end  which  moves,  the  upper 
end  being  continuous  with  the  liver.  In  our  experience  this  condition  has 
always  occurred  in  patients  with  thin  abdominal  walls  in  whom  a  diagnosis 
could  be  made  after  a  careful  examination.  Should  it,  however,  exist  in  an 
obese  patient,  such  a  definite  diagnosis  could  probably  not  be  made. 

In  this  patient,  the  empty  space  which  exists  when  the  kidney  is  dis- 
placed is  so  distinct  that  there  can  scarcely  be  a  doubt  concerning  the  di- 
agnosis. 

Another  test  might  be  used  by  inflating  the  colon  with  gas  by  means 
of  an  air  pump  attached  to  a  tube  inserted  into  the  rectum.  The  distended 
colon  would  pass  below  the  mass  if  it  were  a  distended  gall  bladder  or  a 
deformed  lobe  of  the  liver,  while  it  would  pass  to  the  inner  side  of  the 
mass  if  it  were  the  kidney.  This  method,  although  theoretically  of  great 
value,  is  in  practice  useful  only  to  confirm  a  diagnosis.  If  too  much  weight 
is  placed  upon  this  method  the  surgeon  is  likely  to  err  in  his  diagnosis. 

Etiology.  Aside  from  the  traumatic  cause,  we  have  here  the  history  of 
two  pregnancies,  which  is  another  common  cause  of  movable  kidney.  In 
many  of  these  cases,  a  chronic  appendicitis,  gastritis,  enteritis  or  gall  stones, 
or  all  of  these,  exist  at  the  same  time,  and  it  is  difficult  to  say  whether  or 
not  there  is  any  casual  relation  between  these  various  conditions  or  whether 
their  co-existence  is  merely  a  coincidence,  or,  again,  whether  they  are  all 
dependent  upon  an  infection  from  the  alimentary  canal. 

Many  years  ago  Pawlik  directed  our  attention  to  the  fact  that  of  the 
patients  coming  into  his  gynecological  clinic  of  all  women  who  did  the  work 
of  laborers  in  the  streets,  upon  buildings  or  on  the  farms  and  who  had 
borne  children,  seventy-five  per  cent,  were  sufl'ering  from  this  condition,  but 
that  of  all  such  there  were  but  a  few  in  whom  the  amount  of  disturbance 
caused  by  the  loose,  displaced  kidney  was  sufficient  to  require  treatment. 
Our  own  observations  have  confirmed  this  in  the  study  of  many  hard-work- 
ing, foreign  women  who  came  under  care  for  the  treatment  of  other  condi- 
tions, and  in  whom  the  general  physical  examination  revealed  the  presence 
of  this  anomaly.  Scarcely  one  per  cent,  of  all  patients  in  whom  the  kidney 
is  movable  to  a  markedly  abnormal  degree  require  operation.  On  the  other 
hand,  we  observe  twenty  cases  in  whom  nephrorrhaphy  has  been  performed 
without  the  slightest  benefit,  for  each  case  in  which  the  patient  has  been 
benefited  by  the  operation. 

Indications  for  operation.  In  the  presence  of  an  anatomical  lesion  which 
may  be  easily  removed,  to  which  the  patient's  suffering  is  directly  referred, 
and  wherein  the  sudden  occurrence  apparently  initiated  the  pain,  there  can 
scarcely  be  a  doubt  regarding  the  indication  for  operation.  This  is  especially 
true  in  patients  who  are  not  otherwise  neurotic  and  who  were  in  good 
health  before  the  accident  occurred  which  loosened  the  kidney,  and  in  whose 
case  there  is  no  pending  question  of  liabilit;^  for  personal  injury.     AU  of 


SUEGERY  OF  THE  GENITO-URINARY  TRACT  559 

these  matters  must  be  carefully  considered,  because  otherwise  the  operation 
must  become  more  and  more  discredited. 

The  preparatory  treatment  should  be  the  same  as  for  ordinary  abdom- 
inal sections. 

Technique.  The  same  incision  which  has  been  described  in  connection 
with  the  previous  case  will  be  made,  the  fatty  capsule  opened,  and  the  kid- 
ney brought  up  for  inspection.  It  is  quite  normal,  aside  from  the  fact  that 
it  is  so  freely  movable.  The  pelvis  is  not  distended  and  it  is  evidently  free 
from  infection. 

So  large  a  proportion  of  patients  suffering  from  movable  kidney  suffer 
also  from  chronic  appendicitis  and  gall  stones  that  we  usually  examine  these 
organs  at  the  same  time,  provided  the  kidney  is  free  from  infection.  This 
can  be  done  by  making  a  small  opening  in  the  peritoneum  in  front  of  the 
colon,  inserting  one  or  two  fingers  and  palpating  these  organs.  In  this  case 
we  find  the  gall  bladder  free  from  disease^  but  the  appendix,  which  is  four 
inches  in  length,  club-shaped  at  its  distal  end  and  constricted  at  its  cecal 
end,  contains  a  number  of  fecal  concretions.  We  will  bring  the  appendix 
and  the  lower  end  of  the  cecum  out  through  the  opening  in  the  peritoneum 
and  remove  the  former  by  the  method  described  in  the  section  on  appendicitis. 
The  opening  in  the  peritoneum  is  then  sutured  with  catgut  and  the  operation 
upon  the  kidney  is  proceeded  with. 

The  kidney  is  first  brought  out  of  the  wound,  as  shown  in  the  plate, 
then  its  capsule  is  split  longitudinally  a  distance  of  two  to  three  inches  and 
loosened  from  the  surface  of  the  kidney  a  distance  of  about  one  inch,  as 
shown.  Next  a  strand  of  iodoform  gauze  is  passed  underneath  the  lower 
pole  of  the  kidney,  likewise  shown  in  the  plate,  and  fastened  to  the  capsule 
of  the  kidney  by  means  of  a  fine  catgut  suture  on  either  side.  The  kidney, 
together  with  the  attached  gauze,  is  then  replaced  in  the  body,  as  shown  in 
the  next  plate,  and  the  true  capsule  of  the  kidney  is  sutured  to  the  fascia 
of  the  quadratus  lumborum  muscle  by  means  of  a  number  of  chromicized 
catgut  sutures,  as  indicated.  A  small  strand  of  iodoform  gauze  is  passed 
down  to  the  denuded  surface  of  the  kidney,  and  then  the  entire  wound  is 
sutured,  with  the  exception  of  the  space  occupied  by  the  strands  of  iodoform 
gauze.  These  are  removed  about  ten  days  or  two  weeks  after  the  operation ; 
by  which  time  vigorous  granulation  tissue  will  have  developed,  later  forming 
connective  tissue  to  keep  the  kidney  in  place. 

Many  surgeons  do  this  operation  without  the  use  of  the  gauze  and  claim 
equally  perfect  results,  hence  this  part  of  the  procedure  can  hardly  be 
considered  absolutely  necessary.  It  seems  as  though,  in  this  case,  the  removal 
of  the  appendix,  with  its  enteroliths,  is  likely  to  give  the  patient  quite  as 
much  relief  as  the  nephrorrhaphy.  This  has  been  borne  out  by  our  clinical 
observations.  Patients  in  whom  no  lesion  is  corrected  except  the  movable 
kidney,  rarely  make  a  satisfactory  recoverj^  while  quite  the  contrary  is  true 
of  those  in  whom  some  other  important  lesion  has  been  found  and  corrected. 

The  amount  of  displacement  which  we  have  found  in  this  case  might  easily 
have  caused  an  obstruction  of  the  ureter  and  a  consequent  hydronephrosis. 
This  may  occur  as  a  result  of  an  acute  bend  or  twist  in  the  ureter.  In  either 
event  simple  drainage  as  practised  in  the  case  described  will  result  in  the 
contraction  of  the  dilated  pelvis  of  the  kidney,  and  suspension  of  the  kidney 
in  its  normal  position,  according  to  the  method  just  outlined,  will  prevent 
the  obstruction  to  the  ureter  in  future;  consequently  a  permanent  recovery 
may  be  expected  unless  ulceration  has  resulted  from  the  distortion  of  the 
ureter,  and  this  in  turn  produced  cicatricial  constriction  forming  a  fibrous 
stricture.  The  degree  of  constriction  will  determine  the  form  of  treatment 
in  such  cases.     If  the  constriction  is  only  moderate,  simple  drainage  of  the 


560 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


hydronephrosis,  together  with  nephrorrhaphy,  will  result  in  a  sufficient  de- 
gree of  relief  to  promise  a  complete  recovery,  because  the  connective  tissue 
will  become  softer  and  the  edema  reduced,  and  consequently  the  passage 
of  the  urine  through  the  ureter  will  become  more  and  more  free  and  x>res- 
ently  all  of  the  urine  will  pass  in  the  natural  way.  If,  however,  the  constric- 
tion is  great,  nothing  less  thnn  a  nephrectomy  will  usually  suffice  to  give  re- 


Nephrorrhaphy. 

The  kidney  has  been  replaced,  its  lower  pole  being  supported  by  a  strand  of  iodoform 
gauze.     The  loosened  capsule  has  been  sutured  to  the  muscles  and  fascia  in  the  lumbar  wound. 

Usually  the  number  of  sutures  used  in  attaching  the  capsule  to  the  fascia  is  greater  than 
shown  in  this  figure. 


lief.  It  is,  however,  to  be  hoped  that  in  the  future  plastic  operations  or 
resections  of  the  ureter  will  yield  more  satisfactory  results  than  at  the, 
present  time.  It  is  not  likely  that  dilatation  with  bougies  or  sounds  will 
ever  accomplish  much  in  these  cases  because  of  the  difficulty  one  encounters 
in  introducing  bougies,  the  danger  of  rupturing  the  thin-walled  ureter  and 
the  danger  of  infection.  The  lack  of  permanency  of  results  after  dilatation  of 
strictures  in  other  tubes  in  the  body,  convince  us  that  dilatation  of  ureteral 
strictures  must  be  looked  upon  as  visionary  in  all  except  the  neurotic.     In 


SUKGERY  OF  THE  GENITO-URINARY  TRACT  561 

cases  of  congenital  or  acquired  deformities  causing  obstruction  the  methods 
already  described  are  indicated. 

Billington  operation.  Billington,  of  Birmingham,  has  advised  the  follow- 
ing operation  for  fastening  up  the  kidney,  which  we  have  found  to  be  very 
satisfactory. 

A  posterior  incision  is  made  similar  to  the  one  described  in  the  previous 
operation,  except  that  the  incision  extends  upwards  to  the  upper  level  of  the 
twelfth  rib.  The  kidney  is  exposed  and  its  fatty  capsule  removed.  A  triangu- 
lar flap  of  the  true  capsule  of  the  kidney  is  loosened  from  the  upper  pole  down- 
wards, one-third  the  length  of  the  kidney,  a  curved  forceps  is  now  passed  just 
above  the  twelfth  rib  downward  into  the  kidney  space.  This  forcep  grasps  the 
free  end  of  the  triangular  flap  of  the  kidney  capsule  and  draws  it  up  around 
the  twelfth  rib,  where  it  is  sutured  with  chromic  catgut  to  the  muscles  and 
deep  fascia.  This  brings  one-third  of  the  kidney  up  above  the  upper  border 
of  the  twelfth  rib.  The  kidney  is  then  further  fastened  by  placing  three 
chromic  catgut  sutures  through  the  capsule  and  a  small  portion  of  the  kid- 
ney substance,  and  suturing  to  the  lumbar  muscles.  The  rest  of  the  wound 
is  closed  in  the  usual  manner  without  drainage. 

Complications  of  floating  kidney.  A  considerable  proportion  of  patients 
suffer  at  the  same  time  from  other  intra-abdominal  diseases.  Many  of  them 
have  at  some  time  suffered  from  acute  appendicitis  complicated  with  peri- 
tonitis, followed  by  extensive  adhesions.  It  seems  reasonable  to  suppose 
that  these  adhesions  would  have  a  casual  relation  to  the  development  of 
floating  kidney,  either  by  producing  direct  traction  upon  this  organ  or  by 
necessitating  an  abnormal  amount  of  intra-abdominal  pressure  to  force  the 
intestinal  contents  through  the  intestines  in  the  vicinity  of  the  appendix,  and 
especially  through  the  ileo-cecal  valve. 

To  force  the  intestinal  contents  through  the  ileo-cecal  valve  the  intes- 
tine must  be  fairly  well  fixed  at  its  mesenteric  attachment,  as  is  the  case  with 
the  small  intestine  in  its  normal  condition  or  with  the  colon  when  normal. 
"When  the  enteroptosis  obliterates  this  condition  and  adds  to  it  the  actual 
obstruction  caused  by  the  kinking  which  results  from  enteroptosis  and  adhe- 
sions combined,  the  obstruction  may  of  course  be  extreme  and  the  effects 
of  all  of  these  complications  should  not  be  attributed  to  the  fairly  inoffensive 
loose  kidney. 

A  considerable  number  of  these  patients  also  suffer  from  gall  stones.  It 
is  difficult  to  establish  a  reasonable  casual  relation  between  these  two  con- 
ditions, although  such  a  relation  between  gall  stones  and  appendicitis  is  much 
easier  to  explain  and  it  is  possible  that  both  gall  stones  and  floating  kidney 
in  these  cases  are  secondary  to  appendicitis,  although  this  has  by  no  means 
been  proven.  The  frequency  of  these  two  complications  explains  the  failure 
in  obtaining  symptomatic  relief  in  many  patients  suffering  from  floating 
kidney  in  whom  the  anatomic  result  after  nephrorrhaphy  has  been  perfect. 

PLASTIC  OPERATIONS  ON  THE  PELVIS  OF  THE  KIDNEY 

The  principal  conditions  requiring  plastic  operations  upon  the  pelvis  of 
the  kidney  are  strictures  of  the  ureter  at  its  .iunction  with  the  pelvis  of  the 
kidney,  closure  of  the  pelvis  after  removal  of  stones,  and  the  repair  of  the 
ureter  after  its  -partial  or  complete  detachment  from  the  pelvis  during  opera- 
tions upon  the  kidney.  Even  with  most  careful  suturing  of  the  •pelvis  of  the 
kidney  one  is  apt  to  have  a  leakage  of  urine.  To  overcome  this  condition 
"W.  J.  Mayo  has  devised  and  put  into  practice  a  method  of  utilizing  the  fascia 
which  is  closely  attached  to  the  kidney,  especially  about  the  pelvis,  as  a  pro- 
tection to  the  suture  lines  in  the  part  of  the  kidnev 


562  SURGERY  OF  THE  GENITO-URINARY  TRACT 

In  plastic  operations  upon  the  pelvis  of  the  kidney  for  intermittent  hydro- 
nephrosis with  a  stricture  at  the  juncture  of  the  ureter  and  the  pelvis  of  the 
kidney,  the  operation  is  as  follows:  The  fatty  fascial  flap  is  dissected  back 
as  shown  in  plate.  A  longitudinal  incision  is  made  through  the  ureteropelvic 
juncture ;  this  incision  is  now  sutured  transversely  with  fine  catgut  after  the 
method  of  a  Heinicke-Mikulicz  pyloroplasty  (see  plate)  ;  the  fatty  fascial 
flap  which  was  reflected  in  the  early  part  of  the  operation  is  now  sutured 
back  in  place,  covering  over  the  line  of  suture  uniting  the  pelvis  and  the 
ureter.  Even  though  it  can  be  seen  that  at  some  points  the  suture  in  the 
pelvis  is  not  urine  tight,  yet  after  the  fatty  fascia  flap  is  sutured  over  this 
area,  primary  union  will  usually  take  place  without   any  leakage  of  urine. 

In  operating  for  stones  in  the  pelvis  of  the  kidney  in  patients  whose 
kidneys  are  not  infected  enough  to  require  drainage,  the  incision  in  the 
pelvis  can  be  closed  without  any  leakage  of  urine.  In  cases  of  stone  in  the 
pelvis  it  will  usually  be  found  that  there  is  an  increase  in  the  fatty  tissue  in 
the  region  of  the  pelvis,  which  is  also  adherent  thereto.  In  these  cases  the  inci- 
sion is  made  directly  through  the  fatty  tissue  and  the  pelvis  as  though 
they  were  one. 

After  the  stone  is  removed,  the  incision  in  the  pelvis  and  in  the  fascia 
covering  are  sutured  as  a  part  of  each  other,  with  a  row  of  fine  catgut.  If 
the  opening  in  the  pelvis  has  not  been  injured  during  the  removal  of  the 
stones,  this  one  row  of  sutures  will  usually  be  sufficient  to  prevent  leakage. 
If  the  opening  in  the  pelvis  has  been  torn  during  the  removal  of  the  stones, 
making  an  irregular  edge,  the  opening  is  first  sutured  as  above,  and  then  a 
flap  of  the  fatty  fascia  can  be  made  and  turned  back  to  protect  the  line  of 
suture.  This  flap  does  not  need  to  be  sutured  tightly,  but  two  or  three  cat- 
gut stitches  are  placed  in  such  a  manner  as  to  keep  the  parts  in  apposition. 
A  cigarette  drain  should  be  carried  down  to  the  vicinity  of  the  suture  line 
and  left  in  the  wound. 

DECAPSULIZATION  OF  THE  KIDNEY  FOR  CHRONIC  NEPHRITIS 

While  speaking  upon  this  subject  it  seems  proper  to  describe  a  relatively 
recent  operation  upon  the  kidney  which  has  not  as  yet  earned  a  position 
among  recognized  operations,  but  which  seems  to  be  based  upon  reasonable 
principles.  We  refer  to  the  operation  of  removing  the  true  capsule  of  the 
kidney  for  the  cure  of  chronic  nephritis. 

The  same  incision  is  made  as  in  nephrorrhaphy ;  the  capsule  is  split  in 
the  same  manner  but  throughout  the  entire  convex  surface  of  the  kidney. 
It  is  then  carefully  stripped  down  on  either  side  and  cut  away,  leaving  the 
entire  surface  of  the  kidney  in  contact  with  the  surrounding  tissues.  It 
seems  that  new  blood  vessels  form  in  great  numbers  and  that  the  remnants 
of  kidney  tissue  which  have  not  yet  been  destroyed  by  the  disease  will  suffice 
to  carry  on  the  function  of  the  organ  to  a  very  marked  extent  after  this 
operation. 

As  we  have  stated  above,  however,  this  procedure  has  not  as  yet  passed 
through  a  sufficient  period  of  observation  to  be  established  as  a  recognized 
operation.  Since  the  above  was  written  a  few  years  ago  the  method  has 
been  much  lauded  by  some  authors  and  thoroughly  condemned  by  others. 
The  prevailing  opinion  at  the  present  time  seems  to  be  that  in  cases  in  which 
the  nephritis  is  due  to  obstruction  of  the  circulation  caused  by  malposition 
of  the  kidne^^  this  operation,  combined  with  nephrorrhaphy,  may  be  of  bene- 
fit.   It  is  certain  that  in  such  cases  albuminuria  will  disappear. 

The  number  of  these  cases  is  so  small,  however,  that  it  is  not  of  very 
great  importance.     In  connection  with  Dr.  George  Suker  we  were  able  to 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


563 


demonstrate  that  in  no  case  in  which  there  existed  an  albuminuric  retinitis 
at  the  time  of  operation  was  any  permanent  improvement  obtained. 

RESECTION   OF  THE  KIDNEY 

This  operation  is  but  rarely  indicated,  as  the  reason  for  which  one  would 
be  likely  to  perform  it  is  the  removal  of  tumors.  The  kidney  is  so  seldom  the 
seat  of  benign  tumors  that  this  condition  scarcely  deserves  consideration,  the 
small  benign  cyst  having  been  mentioned  before.    In  malignant  disease  of  the 


Renal  Calculus  Filling  Entire  Cavity  of  Ekxal  I'ei.vis,  fiKiiovED  Through  Pyelotomt. 

kidney  even  the  complete  removal  of  the  organ  promises  but  little ;  hence 
a  resection  would  almost  certainly  be  followed  by  a  rapid  recurrence.  In 
severe  crushing  injuries  a  resection  sometimes  becomes  necessarJ^  In  these 
cases  the  extent  of  the  excision  will  depend  upon  the  degree  of  the  trauma. 
It  should  be  in  the  form  of  a  wedge-shaped  piece  in  order  to  permit  of  the 
closure  of  the  defect. 

Sutures  are  likely  to  cut  through  the  kidney  tissue  if  applied  directly, 
but  if  passed  through  gauze  folded  upon  itself  from  two  to  four  times,  then 
through  both  edges  of  the  wound,  then  again  through  layers  of  gauze,  then 


564  SURGERY  OF  THE  GENITO-URINARY  TRACT 

back  in  the  opposite  direction,  they  can  be  tied  without  cutting.  These 
sutures  should  be  of  catgut  which  will  last  about  ten  days  before  being  ab- 
sorbed. The  strips  of  gauze  may  be  permitted  to  project  from  the  wound 
so  as  to  be  withdrawn  when  they  are  freed  by  the  absorption  of  the  catgut 
sutures. 

The  same  plan  may  be  employed  after  nephrotomy  if  the  hemorrhage  is 
so  severe  that  it  cannot  be  controlled  by  tamponing.  If  drainage  of  the  pelvis 
of  the  kidney  is  desired,  in  a  case  in  which  this  plan  is  indicated  because  of 
severe  hemorrhage,  one  or  two  rubber  drains  may  be  wrapped  in  iodoform 
gauze  and  inserted  into  the  pelvis  of  the  kidney,  and  then  the  sutures  applied 
as  before,  the  cut  edges  of  the  kidney  being  thus  pressed  against  the  gauze 
surrounding  the  rubber  drains. 

RENAL  CALCULUS 

Since  the  development  of  radiography  it  is  a  rather  rare  case  in  which  a 
positive  or  negative  diagnosis  of  stone  in  the  kidney  or  ureter  cannot  be 
made.  In  a  very  good  plate,  except  occasionally  in  very  fleshy  people,  the 
outline  of  the  kidney,  as  well  as  the  stone,  should  be  shown.  It  should  not 
be  forgotten  that  kidney  stones  are  frequently  bilateral  and  that  a  photograph 
of  both  kidneys  should  be  taken  whenever  a  renal  calculus  is  suspected. 

The  treatment  of  renal  calculus  is  surgical  and  should  be  undertaken  as 
soon  as  the  diagnosis  is  made  and  it  is  evident  that  the  stone  cannot  be  passed. 
Small  stones  will  frequently  pass  after  the  administration  of  large  quantities 
of  distilled  water  accompanied  by  large  doses  of  glycerine. 

When  the  stone  is  in  the  ureter  and  is  small,  an  effort  may  be  made. to 
dislodge  it  by  distending  the  ureter  with  glycerine  through  a  ureteral  catheter. 

Or,  if  it  be  low  down  or  lodged  at  the  ureteral  orifice,  it  may  be  grasped 
with  a  pair  of  forceps  and  removed  through  a  cystoscope,  as  described  under 
the  heading  of  cystoscopy. 

Pyelotomy.  In  case  a  stone  is  located  in  the  pelvis  of  the  kidney  the 
diameter  of  which  does  not  exceed  two  or  three  cm.,  it  can  usually  be  removed 
by  splitting  the  pelvis  posteriorly  in  the  direction  of  the  ureter.  This  should 
of  course  not  be  done  if  the  stone  is  very  large,  with  sharp  projections  extend- 
ing into  the  calices,  because  in  such  case  the  injury  caused  is  much  greater 
than  it  would  be  after  splitting  the  kidney  longitudinally.  The  finger  should 
be  inserted  into  the  kidney  pelvis  through  the  opening  and  a  careful  search 
made  for  further  separate  stones.  The  stone  removed  should  be  examined 
to  determine  whether  any  fragment  has  been  broken  of£  in  its  extraction. 
The  wound  should  be  drained  by  a  fine,  soft,  split,  rubber  drainage  tube,  and 
a  few  cigarette  drains  should  be  passed  down  to  the  kidney  pelvis  to  drain 
the  surrounding  loose  tissue. 

In  all  of  these  cases  the  patient  should  permanently  drink  only  distilled 
water,  or  spring  water  which  is  practically  free  from  any  mineral  substances, 
because  in  this  way  recurrence  may  be  prevented. 

EXCISION  OF  THE  URETER 


If  the  ureter  is  diseased  in  connection  with  the  kidney,  which  is  not 
uncommon  in  tuberculosis,  it  may  be  excised  by  following  it  from  above 
downward.  If  disease  of  the  ureter  is  diagnosed  before  the  operation  is 
begun  it  is  better  to  make  an  oblique  incision  so  as  to  carry  the  lower  end 
thereof  to  a  point  near  the  anterior  superior  spine  of  the  ilium,  provided 
the  posterior  incision  has  been  chosen.  If  the  anterior  incision  has  been 
selected  it  is  well  to  split  the  outer  edge  of  the  rectus  abdominis  muscle 


SURGERY  OF  THE  GENITO-URINARY  TRACT  565 

longitudinally.  This  incision  may  be  lengthened  to  suit  the  convenience  of 
the  operator.  When  the  bladder  is  reached  the  ureter  is  cut  off  and  a  small, 
purse-string  suture  applied  to  cover  the  stump.  The  wound  is  then  closed 
with  two  or  three  rows  of  catgut  sutures,  unless  infection  has  taken  place 
from  an  ulcerated  ureter  or  from  pus  in  the  pelvis  of  the  kidney,  in  which 
event  the  wound  should  be  drained  with  iodoform  gauze  above  and  below 
and  the  intervening  portion  sutured  in  order  to  prevent  the  formation  of  a 
hernia. 

After  the  kidney  and  the  ureter  have  been  removed  the  suppuration  will 
subside  rapidly,  even  if  it  has  not  been  possible  to  effect  the  removal  without 
spilling  some  of  the  pus  contained. 

Exposing  the  ureter.  Dr.  John  M.  Binnie  has  described  a  simple  method 
of  exposing  the  pelvic  portion  of  the  ureter. 

With  the  patient  in  the  Trendelenburg  position  a  median  incision  is  made 
beginning  close  to  the  pubic  bone  and  extending  upward,  exposing  the  space 
of  Retzius  in  the  usual  manner.  No  muscle  fibres  are  cut  but  the  recti  are 
retracted  to  either  side.  The  point  where  the  paretial  peritoneum  is  reflected 
onto  the  bladder  is  noted  and  care  taken  not  to  open  the  peritoneal  cavity. 
Starting  at  the  bladder  the  peritoneum  is  wiped  away  toward  the  median  line 
separating  it  from  the  bladder  and  pelvic  wall,  thus  exposing  the  ureter. 
With  retraction  one  gets  a  complete  exposure  of  the  ureter  and  any  neces- 
sary procedures  may  be  carried  out  under  the  guidance  of  the  eye.  Drain- 
age, if  necessary,  may  be  instituted  through  the  original  incision  or  through 
a  separate  stab  wound, 

CALCULUS  IN  THE  URETER 

The  symptoms  in  this  condition  at  the  time  the  patient  comes  under  the 
care  of  the  surgeon  usually  simply  consist  of  localized  pain,  but  there  is  always 
a  history  of  renal  colic  preceding  the  complaint. 

The  pain  may  be  at  any  point  in  the  course  of  the  ureter,  although  the 
calculus  is  practically  always  located  at  one  of  three  points,  viz.,  (1)  at  the 
beginning  of  the  ureter,  (2)  at  a  point  where  the  ureter  passes  over  the  edge 
of  the  iliacus  muscle,  and  (3)  just  before  the  ureter  empties  into  the  bladder. 

The  stone  may  almost  always  be  located  with  the  X-ray,  provided  the 
intestinal  tract  has  been  thoroughly  emptied  by  the  use  of  castor  oil  and 
enemata,  and  of  course  provided  that  the  apparatus  and  technique  employed 
are  good.  Occasionally  a  fecal  concretion  in  the  appendix  may  be  mistaken 
for  a  renal  calculus  in  the  skiagram,  and  at  times  a  calcareous  phlebolith 
has  been  so  mistaken.  Of  course  if  the  colon  has  not  been  properly  emptied 
hardened  fecal  masses  may  cause  a  shadow  which  will  be  mistaken  for  a 
calculus.  Then  again,  at  times  a  renal  calculus  may  be  so  transparent  that 
it  will  not  cause  a  sufficient  shadow  to  be  recognized  on  the  plate. 

Ordinarily,  however,  this  method  of  diagnosis  is  eminently  satisfactory, 
especially  if  a  shadow-casting  catheter  has  been  passed  in  the  ureter  before 
the  radiograph  has  been  taken.  In  this  way  the  relative  positions  of  stone 
and  ureter  can  be  determined. 

Treatment.  An  abdominal  incision  is  made  directly  over  the  seat  of  the 
stone,  according  to  the  plan  for  abdominal  incisions  as  indicated  heretofore. 
The  peritoneum  is  split  longitudinally  over  the  ureter,  then  the  latter  is  lifted 
into  view  and  the  surrounding  area  tamponed  away  with  moist  gauze  pads, 
then  a  longitudinal  incision  is  made  once  and  a  half  the  length  of  the  diameter 
of  the  stone  and  directly  over  the  most  prominent  portion  thereof,  in  order 
that  the  stone  may  be  removed  without  crushing  or  tearing  the  wall  of  the 
ureter.    The  stone  is  then  lifted  out  and  the  edges  of  the  wall  of  the  ureter 


566  SURGERY  OF  THE  GENITO-URINARY  TRACT 

permitted  to  fall  together.  A  rubber  drainage  tube  with  a  notch  cut  out  of  its 
lower  end  is  now  placed  down  upon  the  ureter  at  the  point  of  the  opening  and 
held  in  position  by  a  fine  catgut  suture,  then  this  tube  is  surrounded  by  four 
or  five  cigarette  drains  which  are  all  permitted  to  pass  out  of  the  abdominal 
wound  with  the  rubber  tube. 

Should  the  ureter  be  enlarged  above  the  point  at  which  the  stone  was 
located  the  rubber  tube  is  carried  into  the  lumen  of  the  ureter,  but  if  there 
has  been  no  obstruction  this  is  not  necessary. 

SECTION  OF  THE  URETER 

Van  Hook  operation.  If  the  ureter  is  cut  during  an  operation,  except  in 
cases  in  which  this  is  done  for  the  removal  of  a  malignant  growth,  an  attempt 
should  be  made  to  repair  the  damage  immediately.  If  the  section  is  at  any 
point  more  than  a  few  cm.  distant  from  the  bladder  it  is  best  to  telescope  the 
upper  segment  either  directly  into  the  lower  segment  or  through  a  lateral  in- 
cision, according  to  the  method  introduced  by  Van  Hook.  This  operation  con- 
sists in  passing  a  probe  into  the  upper  end  of  the  lower  segment  and  cutting 
down  upon  this  probe  one  and  one-half  cm.  lower  down,  making  a  lateral  slit 
5  mm.  in  length,  then  ligating  the  upper  end  of  the  lower  segment,  then  a 
tine  silk  suture  is  passed  through  one  edge  of  the  lower  open  end  of  the  upper 
segment,  then  both  threads  are  threaded  in  one  needle  which  is  passed  up 
the  lumen  of  the  lower  segment  through  the  lateral  slit  and  out  through  the 
opposite  wall  one  cm.  beyond  the  distal  end  of  the  lateral  slit.  Thus  the 
lower  end  of  the  upper  segment  is  telescoped  into  the  lumen  of  the  lower 
segment  through  the  lateral  slit.  The  edges  of  the  slit  are  carefully  sutured 
to  the  side  of  the  upper  segment  as  shown  in  the  plate. 

In  case  the  section  has  occurred  within  a  few  cm.  of  the  bladder  the  ureter 
is  laid  bare  and  loosened  for  a  distance  of  two  cm.,  then  a  convenient  point  is 
chosen  in  the  wall  of  the  bladder  and  after  making  a  slit  in  the  peritoneal 
covering  the  bladder  wall  is  tunneled  obliquely  with  a  trocar.  The  end  of 
the  ureter  is  then  split  in  halves  at  its  distal  end  and  each  half  transfixed 
with  a  fine  silk  suture  both  ends  of  which  are  then  threaded  upon  a  needle. 
These  needles  are  passed  through  the  opening  made  by  the  trocar  separately 
and  then  the  wall  of  the  bladder  is  transfixed  one  cm.  to  each  side  of  the  tro- 
car opening,  as  shown. 

In  order  to  make  the  next  step  possible  a  sound  is  passed  into  the  bladder 
and  its  end  is  engaged  in  the  open  end  of  the  canula  of  the  trocar  which  is  in 
the  bladder,  and  as  the  canula  of  the  trocar  is  withdrawn  the  end  of  the  sound 
is  passed  out  through  the  wall  of  the  bladder.  The  open  end  of  the  ureter 
is  then  threaded  upon  this  end  of  the  sound  and  as  the  latter  is  again  drawn 
into  the  bladder  the  end  of  the  ureter  is  slipped  in  with  it,  when  the  two 
threads  are  drawn  taut  and  tied.  The  bladder  wall  is  sutured  with  a  few  very 
fine  catgut  stitches  to  the  side  of  the  ureter  and  the  peritoneum  is  closed  over 
all.  A  retention  catheter  is  inserted  and  the  patient  is  given  half  a  pint  of 
distilled  water  with  five  drops  of  dilute  aromatic  sulphuric  acid  every  two 
hours. 

A  soft  rubber  drainage  tube  and  several  cigarette  drains  are  passed  down 
to  the  point  of  anastomosis  and  out  of  the  lower  angle  of  the  wound.  These 
are  left  in  place  four  days  unless  leakage  occurs,  in  which  event  they  are  left 
ten  days,  unless  the  leakage  subsides  sooner.  The  catheter  is  left  in  place 
ten  days,  being  removed  for  two  hours  twice  each  day,  in  the  male,  after  the 
second  day.    In  the  female  a  Jacob's  retention  catheter  is  used  which  need 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


567 


not  be  removed  for  ten  days  unless  phosphates  accumulate  in  its  lumen,  which 
has  never  been  the  case  in  patients  who  received  the  aromatic  sulphuric  acid 
and  distilled  water,  as  indicated  above,  although  formerly  we  had  much  annoy- 
ance from  this  source. 


Anastomosis  of  the  Ureter  by  Van  Hook's  Method. 


PERMANENT  URETERAL  FISTULA 


In  cases  in  which  a  large  portion  of  the  lower  end  of  the  ureter,  either 
on  one  or  on  both  sides,  has  been  destroyed  intentionally  or  accidentally,  it 
may  seem  wise  to  preserve  the  kidney  although  if  the  fellow  kidney  is  normal 
this  is  usually  not  necessary,  as  the  patient  loses  more  from  discomfort  and 
the  danger  of  infection  than  he  gains  from  possessing  the  additional  kidney. 
But  if  the  other  kidney  is  not  normal,  or  if  the  lower  portions  of  both  ureters 


568  SURGERY  OF  THE  GENITO-URINARY  TRACT 

have  been  removed,  as  is  commonly  the  case  in  excision  of  the  bladder  for 
carcinoma,  then  it  is  proper  to  provide  for  a  comfortable  ureteral  fistula. 

For  a  time  it  seemed  as  though  this  could  be  accomplished  by  transplant- 
ing the  ureter  into  the  sigmoid  flexure  of  the  colon,  but  all  of  the  patients  died 
of  ascending  infection  until  recently  when  animal  experiments  seem  to  have 
shown  that  by  transplanting  the  ureter  into  the  sigmoid  by  passing  obliquely 
through  the  wall  and  then  between  the  muscular  and  mucous  layer  for  a  dis- 
tance, and  then  permitting  the  end  of  the  ureter  to  project  for  a  distance  of 
one  cm.  beyond  the  mucous  membrane  into  the  lumen  of  the  intestine,  this 
accident  may  be  avoided.  Such  a  plan  of  operation  looks  reasonable  and  has 
proven  satisfactory  experimentally. 

As  most  of  these  patients  die  from  a  recurrence  of  their  original  carcinoma 
within  a  few  years,  it  seems  as  though  they  were  entitled  to  the  comfort  which 
this  operation  offers. 

We  have  not  had  an  opportunity  to  test  this  method  above  mentioned  and 
none  of  the  cases  in  which  it  has  been  employed  have  been  operated  long 
enough  to  represent  a  test,  hence  we  must  be  satisfied  for  the  present  with  the 
statement  as  given. 

Watson's  device.  Watson  invented  a  device  for  collecting  urine  from 
ureteral  fistulaj  located  in  the  lumbar  region  which  works  well. 

The  ureter  is  simply  passed  throiigh  the  edge  of  the  quadratus  lumborum 
and  the  latissimus  dorsi  muscles  and  permitted  to  project  five  mm.  beyond 
the  skin  where  it  is  attached  with  fine  silk  sutures.  Watson's  device  consists 
of  a  box  with  a  drainage  opening  and  spout  to  which  a  rubber  tube  is  attached 
and  which  carries  the  urine  into  a  rubber  bag.  The  rim  of  the  box  is  fitted 
with  a  pneumatic  tube  which  adjusts  perfectly  against  the  patient's  back. 
The  box  is  held  tightly  in  place  by  a  broad  elastic  belt  encircling  the  patient's 
body.  The  pneumatic  edge  of  the  box  protects  the  patient  against  harm  from 
pressure  and  secures  his  comfort.  By  placing  a  few  drops  of  formalin  in  this 
receptacle,  and  having  two  of  these  so  that  they  may  be  worn  on  alternate 
days,  they  will  not  become  offensive.  This  method  is  much  safer  than  the 
other,  and  in  patients  not  operated  for  malignant  growths  it  seems  better  to 
employ  this  plan  until  the  latter  class  of  cases  has  definitely  demonstrated  the 
safety  of  the  oblique  implantation  of  the  ureters  into  the  sigmoid. 

Of  the  various  methods  which  have  been  recommended  that  described  above 
seems  to  promise  the  greatest  safety. 

EXSTROPHY  OF  THE  BLADDER 

The  condition  of  exstrophy  of  the  bladder  is  so  distressing  that  we  describe 
an  operation  which  promises  to  become  generally  adopted,  although  our  per- 
sonal experience  is  still  too  limited  to  warrant  recommending  it  on  that  ground 
alone.  The  entire  number  of  cases  which  have  been  operated  by  this  method 
is  also  quite  small,  and  in  many  of  them  the  ultimate  result  has  not  been  re- 
ported, but  all  the  operations  which  were  in  use  before  the  introduction  of  this 
one  can  be  applied  in  only  a  small  number  of  patients  and  do  not  promise  very 
satisfactory  results  at  best, .while  this  procedure  seems  so  far  to  be  most  satis- 
factory. 

Since  the  above  was  written  we  have  performed  the  operation  six  times 
with  five  recoveries,  one  patient  having  died  from  peritonitis.  Another  patient 
died  two  years  later  from  strangulated  hernia,  two  are  still  well  and  two 
others  have  not  been  heard  from  and  the  sixth  case  died  from  nephritis.  The 
physician  caring  for  the  patient  considered  it  a  case  of  septic  nephritis  due  to 
ascending  infection.  The  death  occurred  after  an  illness  of  a  few  weeks  and 
after  the  patient  had  been  well  for  five  years  following  operation. 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


569 


Preparation  for  operation.  Two  days  before  the  operation  the  patient  is 
given  two  ounces  of  castor  oil,  in  order  to  remove  as  much  of  the  mucus  and 
other  contents  of  the  alimentary  canal  as  possible  with  slight  irritation.  From 
this  time  on  until  the  operation  is  performed,  the  patient  is  given  only  concen- 
trated sterilized  food,  so  as  to  leave  the  alimentary  canal  in  as  nearly  an  aseptic 
condition  as  can  be.  Xo  enema  is  given  until  the  patient  is  anesthetized;  then 
the  rectum  and  colon  are  very  thoroughly  irrigated  with  boric  acid  solution, 
and  after   the  water  returns  perfectly   clear  the   sphincter   ani  muscles    are 


■  ^ 


Exstrophy  of  the  Bladder.     "B"  Exstrophy,  "S"  ScRoruii,  "T"'  Head  of  Penis. 

stretched  gently,  but  very  thoroughly.  Then  the  rectum  is  once  more  thor- 
oughly irrigated.  The  patient  is  placed  in  the  Trendelenburg  position  and 
the  bladder  is  carefully  disinfected. 

Mydl's  operation.  The  bladder  is  loosened  from  the  abdominal  wall 
throughout  the  entire  distance,  two  fine  probes  are  inserted  into  the  ureters, 
great  care  being  taken  not  to  disturb  the  little  valve-like  openings  at  the  end 
of  the  ureters.  Then  an  elliptical  portion  of  the  bladder  wall,  from  two  to 
three  centimeters  in  diameter,  is  excised  in  such  a  manner  that  the  openings 
of  the  ureters  are  as  near  the  middle  of  this  portion  as  possible.  Care  must  be 
taken  in  this  step  of  the  operation  not  to  injure  the  ureters.  It  is  best  to  begin 
the  incision  below  and  then  lift  up  the  portion  of  the  bladder  and  to  observe 
the  direction  in  which  the  probes  extend  into  the  ureters.  In  this  manner 
injury  to  the  latter  is  readily  avoided.    The  segment  of  the  bladder,  together 


570 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


Avith  the  ureters,  is  now  held  upwards,  the  urine  which  issues  from  the  ureters 
is  sponged  gently,  and  the  remaining  portion  of  the  bladder  is  rapidly  dissected 
away.  Then  the  sigmoid  tiexure  is  brought  up  into  the  wound  and  a  longi- 
tudinal incision  made  through  the  middle  of  the  longitudinal  muscular  band, 
two  centimeters  in  length.  The  segment  of  the  bladder  is  inserted  into  the 
colon  and  held  in  place  with  four  silk  stitches,  two  at  the  end  of  the  longi- 
tudinal incision  in  the  colon  and  one  in  each  edge  of  the  incision  half  way 
between  these  two  stitches.  Four  sutures  are  previously  placed  in  the  wall  of 
the  colon,  one  on  each  side  of  the  middle  of  the  incision  and  one  just  beyond  the 
end  of  the  incision,  to  be  utilized  for  the  purpose  of  manipulating  the  intestine 


Removal  uj-   i  ^ai.-,  aau  .-iukotxjm  for  Carcinoma. 


ij.  j--4^pf>c-. 


With 
perineum, 


excision    of    inguinal   lymphatics    and    transplantation    of    stump    of    urethra    into 
showing  primary  incision. 


while  the  segment  of  the  bladder  is  sutured  in  place.  The  first  row  of  sutures 
is  passed  through  the  entire  thickness  of  the  bladder  and  through  the  entire 
thickness  of  the  intestine,  care  being  taken  to  repeat  about  the  fourth  stitch 
in  the  continuous  suture  in  order  to  prevent  slipping — after  the  manner 
described  in  the  section  on  intestinal  surger3\  After  the  entire  segment  of  the 
bladder  has  been  sutured  into  this  opening,  Avith  the  mucous  membrane  facing 
the  lumen  of  the  intestine,  a  second  row  of  sutures  is  applied  which  penetrates 
neither  the  portion  of  the  bladder  nor  the  intestine,  but  simply  grasps  a  suffi- 
cient amount  of  tissue  to  bring  the  serous  surfaces  carefully  and  thoroughly  in 
apposition  throughout  the  entire  course.  The  intestine  is  then  dropped  into 
the  abdominal  cavity.  Care  must  then  be  taken  to  isolate  the  layers  of  the 
abdominal  wall  because  the  latter  is  bound  to  be  defective  in  these  cases,  and 
if  this  precaution  is  not  taken  a  ventral  hernia  is  very  likely  to  result.    This 


SUKGERY  OF  THE  GENITO-URINARY  TRACT 


571 


condition  later  resulted  in  the  formation  of  a  strangulated  hernia  in  one  of  our 
cases  which  eventuated  in  the  death  of  the  patient.  After  these  layers  have 
been  carefully  isolated  the  abdominal  wall  is  closed  in  the  manner  described  in 
the  section  on  abdominal  surgery. 

It  is  of  great  importance  in  these  cases  to  strap  the  wound  thoroughly  with 
rubber  adhesive  straps,  in  order  to  remove  the  tension  as  much  as  possible 
from  the  stitches  in  the  abdominal  wound.  It  is  also  important  to  administer 
for  the  first  two  weeks  after  the  operation  only  such  food  as  will  give  rise  to 
the  formation  of  as  little  gas  as  possible,  in  order  to  reduce  the  strain  upon  the 
stitches    of   the    abdominal   wound   to    a   minimum.      The    stretching   of  the 


Complete  Excision  of  Male  Genitalia  for  Carcinoma  of  Penis. 

1,  urethra;    2,  vascular  portion  of  penis;   3,  vessels  of  cord;   4,  vas   deferens.     Showing 
urethral  stump  transplanted  into  perineum  through  buttonhole,  the  end  proiecting  5  mm. 


sphincter  ani  muscle  in  the  beginning  of  the  operation  will  aid  in  preventing 
accumulation  of  gas  and  will  reduce  the  pressure  upon  the  wound  in  the  intes- 
tine. Should,  however,  the  sphincter  contract  sooner  than  desirable  a  rectal 
tube  should  be  inserted  and  kept  freely  open,  in  order  to  prevent  the  accumu- 
lation of  flatus  in  the  rectum. 

These  patients  are  very  comfortable  after  the  operation.  They  are  able  to 
remain  perfectly  dry,  sleep  all  night  and  evacuate  the  urine  from  the  rectum  as 
often  as  they  would  normally  evacuate  the  bladder.  They  are  no  longer  offen- 
sive to  themselves  or  their  friends  and  neighbors  and  they  and  their  families 
look  upon  the  operation  as  a  great  blessing. 

It  is  important  not  to  injure  the  ostium  of  the  ureter,  and  for  this  reason 


572 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


the  probes  -which  are  used  for  marking  the  location  of  the  ostium  and  of  the 
ureter  during  the  operation  should  be  manipulated  with  great  gentleness.  It 
is  undoubtedly  bad  practice  to  leave  ureteral  catheters  in  place  for  several  daj^s 
after  the  operation,  as  recommended  by  some  surgeons,  because  this  would 
surely  injure  the  delicate  valve-like  openings. 

Were  it  not  for  these  delicate  structures  it  seems  unlikely  that  the  opera- 
tion could  have  proved  satisfactory,  although  the  oblique  submucous  implant- 
ation of  the  ureters  may  prove  to  be  satisfactory  in  time. 

Garre's  operation  for  exstrophy.  Professor  Garre,  of  Bohn,  utilizes  the 
cecum  as  a  bladder  in  cases  of  exstrophy. 


V?  -  i  \     i' 


,/)J<|oJ)f.C_' 


CojiPLETE  Excision  of  Male  Genitalia. 


Together  with  inguinal  lym2)haties  and  with  trausjilantation  of  stump  of  urethra  into 
perineum  through  buttonhole  in  skin.  1,  urethra;  5,  fascia  of  internal  oblique  abdominal 
muscle;  6,  internal  oblique  abdominal  muscle;  7,  Poupart's  ligament. 

The  operation  is  performed  in  two  stages.  First  an  abdominal  section  is 
made  and  the  ileum  is  cut  off  about  four  inches  from  the  ileo-cecal  valve.  The 
distal  end  is  closed  with  a  purse-string  stitch,  over  which  is  placed  an  inter- 
rupted Lembert  stitch.  The  ascending  colon  is  cut  off  about  four  inches  from 
the  head  of  the  cecum  and  both  ends  closed  with  interrupted  silk  sutures.  The 
proximal  end  of  the  ileum  is  now  implanted  into  the  ascending  or  transverse 
colon.  An  appendicostomy  is  now  made  and  a  retention  catheter  placed 
through  the  appendix  into  the  cecum.  This  completes  the  first  stage  of  the 
operation  and  the  abdomen  is  closed  in  the  usual  manner.  The  cecum  is  thor- 
oughly irrigated  daily  with  some  mild  antiseptic  solution  for  a  period  of  four 
to  six  weeks.  The  abdomen  is  now  opened  again  and  the  second  step  of  the 
operation  is  completed  hj  transplanting  the  ureters,  together  with  a  small  por- 


SUEGERY  OF  THE  GENI  TO -URINARY  TRACT 


573 


tion  of  the  bladder  around  each  ureteral  opening  into  the  ileum,  the  end  of 
which  was  closed  at  the  primary  operation.  The  rest  of  the  mucous  membrane 
of  the  bladder  is  dissected  out  and  the  defect  in  the  abdominal  wall  closed  as 
thoroughly  as  is  possible.  The  retention  catheter  is  kept  in  place  through  the 
appendix  for  a  couple  of  weeks.  After  this  the  urine  is  allowed  to  collect  in 
the  cecum  and  is  withdrawn  with  an  ordinary^  catheter  about  three  times  daily. 
The  urine  does  not  leak  through  the  appendicostomy  opening. 


I  ' 


>^ 


/*\ 


^ 


X%; 


A 


4 


/ 


A 


Complete  Excision  of  Male  Genitalia  fob  Carcinoma   of  Pexis. 

Together  with  excision  of  lymphatics  of  inguinal  region  and  transplantation   of   stump 
of  urethra  into  perineum  through  buttonhole  in  skin.     Operation  completed. 


PLASTIC  OPERATIONS  FOR  CLOSING  THE  EXSTROPHY 

In  performing  a  plastic  operation  for  the  purpose  of  closing  an  exstrophy 
of  the  bladder  everything  depends  upon  the  amount  of  tissue  that  is  lacking 
and  the  portions  involved.  Each  operation  must  be  planned  with  a  view  to  the 
formation  of  a  bladder  lined  with  mucous  membrane,  that  will  hold  the  urine 
or  that  will  serve  to  direct  the  flow  of  urine  into  a  rubber  urinal.  If  possible 
a  urethra  should  also  be  constructed.  Usually  several  operations  are  required 
and  then  the  results  are  as  a  rule  only  slightly  satisfactory. 

Of  the  plastic  operations  we  have  obtained  the  most  satisfactory  result  in  a 
case  in  which  we  utilized  the  mucous  membrane  of  the  trough-like  urethra  in 
a  hypospadias  for  the  construction  of  a  new  urethra  which  we  passed  out 
through  a  large  trocar  puncture  in  the  perineum.  We  then  made  an  incision 
between  the  mucous  lining  of  the  bladder  and  the  skin  and  then  closed  the 
defect  by  bending  the  pieces  upward  and  suturing  into  this  defect.  A  reten- 
tion catheter  was  placed  into  the  bladder  through  the  new  urethra  and  aro- 


574  SUKGERY  OF  THE  GENITO-URINARY  TRACT 

matic  sulphuric  acid  in  distilled  water  was  given  every  two  hours.    The  patient 
made  a  very  satisfactory  recover3\ 

The  boy  was  only  six  years  old  and  the  operation  Avas  performed  but  three 
years  ago.'  How  the  organ  will  functionate  later  in  life  is  of  course  of  much 
interest. 

AMPUTATION  OF  THE  PENIS 

This  operation  is  done  only  for  the  relief  of  malignant  growths  which,  in 
our  experience,  have  always  been  carcinomatous  in  nature,  although  there  is 
no  reason  why  other  forms  of  malignant  growth  should  not  occur  in  this  organ. 

If  the  disease  is  confined  to  the  distal  end,  it  may  be  so  circumscribed  as 
to  be  completely  removable  by  the  amputation  of  only  a  portion  of  the  organ, 
but  if  any  doubt  exists  it  is  much  safer  for  the  patient  to  make  the  complete 
amputation  at  once,  together  with  a  thorough  removal  of  the  inguinal  lym- 
phatic glands. 

If  the  condition  present  seems  to  warrant  the  removal  of  only  a  portion  of 
the  organ,  the  following  method  should  be  employed : 

A  small  rubber  tube  is  stretched  and  passed  several  times  around  the  penis 
near  its  pubic  attachment  and  then  tied,  in  order  to  make  the  operation  blood- 
less. A  point  is  then  chosen  sufficiently  far  from  the  tumor  to  insure  freedom 
from  invasion.  Usually  this  distance  should  be  at  least  five  centimeters ;  and 
the  greater  the  distance  the  better,  as  these  growths  are  exceedingly  prone  to 
recur  in  this  region.  After  the  point  for  amputation  has  been  chosen  the  skin 
is  divided  with  a  circular  incision  two  centimeters  nearer  the  pubis.  Then  a 
sound  is  introduced  into  the  urethra  and  a  catgut  suture  is  passed  around  each 
corpus  cavernosum,  and  another  around  the  corpus  spongiosum  down  to,  but 
not  through,  the  urethra,  which  may  be  determined  by  the  presence  of  the 
sound  in  the  canal.  These  ligatures  are  carefully  tied.  Then  a  circular  incision 
is  carried  down  to,  but  not  through,  the  urethra,  one  centimeter  away  from  the 
point  at  which  the  ligatures  have  been  applied,  in  a  distal  direction.  Then  the 
tissues  are  stripped  from  the  urethra  for  a  distance  of  one  centimeter  in  the 
distal  direction,  and  then  the  urethra  is  severed. 

The  dorsal  artery  is  now  caught  separately  with  hemostatic  forceps  and 
ligated.  Then  the  elastic  constrictor  is  removed  and  the  stump  will  be  found 
entirely  free  from  hemorrhage.  The  projecting  portion  of  the  urethra  is  then 
split  laterally,  and  carried  through  a  buttonhole  in  the  anterior  skin  flap, 
where  it  is  sutured  in  place  with  horse-hair  sutures.  The  skin  is  then  drawn 
over  the  stump  of  the  penis,  and  a  tenaculum  is  applied  on  each  side,  thus  form- 
ing a  transverse  wound.  The  edges  of  the  skin  are  united  and  a  complete  cov- 
ering of  the  stump  is  formed  in  this  manner.  The  arrangement  of  the  flaps  at 
the  end  of  the  urethra  will  prevent  the  contraction  of  the  canal  at  this  point. 

This  operation  leaves  the  patient  in  a  very  comfortable  condition,  but  un- 
fortunately these  sufferers  do  not  come  under  the  care  of  the  surgeon  early 
enough,  as  a  rule,  to  make  the  procedure  justifiable.  Unless  the  case  is  abso- 
lutely incipient  we  never  advise  this  operation,  because  it  is  almost  always  fol- 
lowed by  recurrences,  and  unfortunately  in  the  recurrent  cases  the  disease  has 
often  advanced  so  far  that  complete  excision  is  no  longer  possible,  while  if  the 
extensive  operation  described  below  is  done  fairly  early  the  relief  is  very  likely 
to  be  permanent. 

Radical  operation.  Fortunately  the  more  complete  operation  gives  satis- 
factory results,  both  as  regards  permanency  of  cure  and  function  of  the 
urethra,  even  in  advanced  cases.  This  operation  is,  however,  much  more  exten- 
sive and  correspondingly  more  severe  as  regards  the  production  of  shock.  It 
contemplates  the  removal  of  the  entire  organ,  together  with  the  scrotum,  with 


SUEGERY  OF  THE  GENITO-URINARY  TRACT 


575 


Hypospadias  Operation. 


II 


Fig.  I  represents  the  flaps  of  the  foreskin  reflected;  the  urethra  carefully  dissected  free; 
a  perforation  has  been  made' through  the  glans  by  means  of  a  trocar;  the  end  of  the  urethra 
has  been  caught  with  fine  pointed  haemostatic  forceps  and  carried  forward  through  the  opening 
in  the  glans. 

Fig.  II  represents  the  flaps  sutured  in  place,  making  an  artificial  frenulum,  the  end  of 
the  urethra  having  previously  been  sutured  in  position  a  little  above  the  center  of  the  glans. 

Taken  from  Dr.  C.  H.  Mayo 's  original  drawings. 


T 


\ 


V 


III 


Hypospadias. 


IV 


Fig.  Ill  represents  the  prepuce  and  a  portion  of  the  skin  from  the  dorsal  surface  of  the 
penis  dissected  up  and  formed  into  a  canal,  with  the  cuticle  turned  in  for  a  lining.  The 
urethra  is  indicated  by  dotted  lines.     It  opens  on  the  inferior  surface  of  the  penis. 

Fig.  IV  represents  the  glans  and  the  penis  tunneled  and  the  newly  formed  urethra  drawn 
through  the  defect  upon  the  dorsal  surface  of  the  penis  closed  with  sutures. 

Taken  from  Dr.  C.  H.  Mayo's  original  drawings. 


576 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


(a) 


C.  H.  Mayo  method. 


(c) 


C.  H.  Mayo  method. 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


ot  ( 


(e) 


C.  H.  Mavo  method. 


{i) 


(g) 


C.  H.  Mayo  method. 


(h) 


578  SURGERY  OF  THE  GENITO-URINARY  TRACT 

its  contents,  and  the  tissues  of  the  spermatic  cords,  as  well  as  the  inguinal 
lymphatic  glands.  It  also  includes  the  transplantation  of  the  remnant  of 
the  urethra  into  the  perineum. 

Technique.  An  incision  is  begun  opposite  the  internal  abdominal  ring  on 
one  side.  It  is  carried  down  over  the  center  of  the  inguinal  canal  around  the 
edge  of  the  scrotum,  sufficient  skin  being  left  to  insure  the  covering  of  the 
entire  defect.  Then  the  incision  is  carried  up  on  the  opposite  side  along  the 
edge  of  the  scrotum  over  the  inguinal  canal  to  a  point  opposite  the  other  in- 
ternal abdominal  ring.  A  transverse  incision  is  made  to  join  the  two  here 
described,  just  below  the  pubis.  The  skin  and  superficial  fascia  are  then  dis- 
sected up  and  all  the  inguinal  lymphatic  glands  carefully  excised.  The  tissues 
of  the  cord  are  then  isolated  and  treated  as  described  in  the  operation  for 
castration.  The  bleeding  vessels  are  carefully  caught  with  hemostatic  forceps, 
in  order  to  reduce  the  loss  of  blood  to  a  minimum.  It  is  desirable  to  make  a 
very  thorough  dissection  of  the  entire  inguinal  region,  so  that  no  infected 
lymphatic  glands  remain.  The  suspensory  ligament  is  severed  from  its  attach- 
ment to  the  pubic  bone  and  then  the  crura  are  loosened  from  their  attachment 
to  the  rami  of  the  pubes. 

It  now  becomes  necessary  to  insert  a  sound  into  the  urethra,  and  the  latter 
should  be  dissected  out  to  a  length  so  as  to  project  half  a  centimeter  beyond 
the  level  of  the  lateral  skin  flaps.  After  isolating  this  length  of  urethra  it  is 
cut  off  at  right  angles,  and  now  the  remaining  tissues  are  loosened  from  their 
attachment  backward.  The  branches  of  the  internal  pubic  arteries  should  be 
caught  before  they  are  severed,  because  quite  a  little  blood  may  be  saved  in 
this  manner.  All  the  blood  vessels  are  then  carefully  ligated.  The  remnant 
of  the  urethra  is  split  anteriorly  and  posteriorly  to  a  distance  of  one-half  centi- 
meter, and  is  sutured  directly  into  the  lower  edge  of  the  wound  in  the  perinettm. 
A  small  retention  catheter  is  introduced  into  the  bladder  and  the  incisions  in 
the  skin  are  closed  throughout  with  sutures.  If  the  dissection  in  the  inguinal 
region  has  been  quite  extensive  it  is  well  to  insert  a  small  split  rtibber  drainage 
tube  on  each  side,  in  order  to  prevent  the  accumulation  of  serum.  Ordinarily, 
however,  the  application  of  thoroughly  fitting  pads  will  make  this  unnecessary. 
An  ordinary  dressing  is  applied  to  the  wotind  and  a  retention  catheter  is  at- 
tached to  a  rubber  drain,  which  is  inserted  in  a  bottle  containing  some  anti- 
septic fluid. 

This  operation  is  usually  performed  in  aged  patients,  and  consequently  it 
is  important  that  it  should  be  done  quickly  and  that  as  little  traumatism  as 
possible  be  inflicted. 

After-treatment.  We  have  found  it  advantageous  to  permit  these  patients 
to  sit  tip  soon  after  the  operation,  on  the  second  or  third  day,  because  this  will 
not  interfere  with  the  healing,  and  because  they  are  prone  to  hypostatic  con- 
gestion, which  can  be  avoided  in  this  manner. 

The  retention  catheter  is  removed  on  the  second  or  third  day  and  the 
patient  permitted  to  evacuate  his  bladder  spontaneously.  In  some  cases  we 
have  permitted  this  from  the  beginning  with  perfect  satisfaction. 

Prognosis.  Our  personal  experience  with  this  operation  has  been  confined 
to  six  cases,  all  of  which  had  been  previously  operated  for  the  relief  of  carci- 
noma, and  in  all  of  them  there  was  not  only  a  recurrence  of  the  disease  in  the 
organ,  but  also  a  recurrence  in  the  inguinal  lymphatic  glands.  To  our  surprise, 
none  of  these  patients  has  died  as  a  restilt  of  a  recurrence.  The  first  patient 
lived  for  three  years  and  died  of  pneumonia.  The  second  lived  for  a  period  of 
six  years  without  recurrence  and  died  of  an  intercurrent  disease.  The  third 
is  alive  after  eleven  years;  the  fourth  we  have  lost  sight  of;  the  fifth  is  well 
after  five  years,  and  the  sixth  is  too  recent  to  be  of  any  importance  in  this  con- 
sideration, the  operation  having  been  performed  not  much  over  one  year  ago, 


SUEGERY  OF  THE  GENITO-URINARY  TRACT 


579 


(i) 


C.  H.  Mayo  method. 


(J) 


■' 

~1. 

/ 

1 

4^ 

/ 

/ 

^ 

/ 

f- 

\ 

■7 

(k) 


C.  H.  Mayo  method. 


(1) 


580 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


(inj 


C.  H.  Mayo  method. 


(0) 


C.  H.  Ma^o  method. 


SURGERY  OF  THE  GENITO-URINARY  TRACT  581 

but  lie  also  is  free  from  recurrence.  In  all  of  these  tlie  operation  was  done 
with  the  greatest  thoroughness,  although  each  ease  at  the  time  of  the  operation 
seemed  hopeless,  judging  from  the  experience  with  carcinoma  in  other  regions 
of  the  body  after  the  lympathic  glands  have  been  involved.  In  all  of  these  we 
employed  the  X-ray  in  the  after-treatment  with  the  exception  of  the  first  case. 

HYPOSPADIAS 

This  deformity  is  so  common  that  it  seems  proper  to  describe  a  simple 
method  for  its  relief,  especially  as  the  presence  of  the  defect  seems  to  give  rise 
to  much  mental  suffering  on  the  part  of  the  parents  of  the  afflicted  child. 

The  urethra  may  open  just  at  the  beginning  of  the  glans  and  then  the 
operation  to  be  employed  is  exceedingly  simple.  It  was  primarily  described 
by  Carl  Beck. 

An  incision  is  made  through  the  skin  in  the  median  line  from  its  opening 
to  a  point  from  one-third  to  one-half  the  distance  to  the  scrotum.  Skin  flaps 
are  then  dissected  to  either  side,  as  shown  in  plate.  The  urethra  is  then  dis- 
sclcted  perfectly  free  this  entire  distance  back,  great  care  being  taken  not  to 
injure  its  delicate  wall  at  any  time.  The  glans  is  then  transfixed  in  the  direc- 
tion of  the  urethra  by  means  of  a  very  sharp  trocar  three  millimeters  in 
diameter.  Caution  should  be  taken  to  place  this  opening  two  or  three  milli- 
meters above  the  small  dimple  in  the  center  of  the  glans,  which  marks  the  point 
at  which  the  meatus  was  normally  intended,  because  if  this  is  not  done  the 
organ  will  curve  downward  and  there  will  still  exist  an  uncomfortable 
deformity. 

A  pair  of  fine  hemostatic  forceps  is  then  passed  through  the  canal  which 
has  been  made  in  the  glans  in  this  manner  and  the  urethra  is  drawn  through 
the  opening  in  the  manner  shown  in  plate.  It  is  then  carefully  sutured  in  place 
with  two  rows  of  catgut  or  fine  silk  sutures.  The  lateral  skin  flaps  are  then 
united  as  shown.  In  this  manner  the  deformity  can  be  almost  completely  cor- 
rected and  the  functional  conditions  are  very  greatly  improved.  The  tissues  in 
this  region  are  so  elastic  that  they  readily  accommodate  themselves  to  these 
new  relations,  and  the  results  of  this  operation  are  very  satisfactory. 

In  case  the  urethra  opens  far  back  from  the  glans,  another  method  is  indi- 
cated which  will  supply  a  new  urethra  artificially  formed  out  of  the  tissues  of 
the  prepuce,  as  shown. 

The  prepuce  in  cases  of  hypospadias  is  usually  redundant  and  situated  on 
the  dorsal  surface,  overhanging  the  glans  like  a  hood.  The  skin  of  the  penis  is 
noted  for  its  thinness,  having  no  adipose  tissue,  also  for  its  looseness  of  attach- 
ment and  elasticity.  Where  it  is  folded  upon  itself  at  its  cer^-ical  attachment 
its  character  very  nearly  resembles  mucous  membrane. 

The  prepuce  is  extended  as  for  circumcision,  and  two  incisions  are  made 
about  one  inch  apart,  extending  from  its  free  border  to  its  attachment  at  the 
penile  cervix;  the  prepuce  is  luifolded,  forming  a  loop  of  thin  skin  about  six 
centimeters  in  length.  Should  this  not  be  considered  sufficient  to  reach  from 
its  attachment  to  the  hj^iospadiac  opening,  the  two  incisions  are  extended  back 
along  the  dorsum  of  the  penis  until  sufficient  tissue  is  obtained,  when  the  two 
incisions  are  connected  by  a  transverse  one,  and  the  flap  of  the  skin  lifted,  but 
left  attached  to  the  cervix  by  the  inner  surface.  Several  sutures  now  close  the 
lateral  integument  of  the  penis  over  the  denuded  area. 

The  pedunculated  flap  of  prepuce  is  constructed  into  a  tube  with  its  skin  or 
outer  surface  inside,  by  means  of  a  number  of  catgut  sutures.  The  penis  is 
tunneled  by  means  of  a  narrow  bistoury  or  medium  trocar  and  canula,  through 
the  glans,  above  its  groove,  along  the  penis  to  a  point  beneath  the  hypospadiae 
opening,  when  it  is  made  to  emerge  at  one  side  of,  but  close  to,  the  urethra ; 


582  SURGERY  OF  THE  GENITO-URINARY  TRACT 

the  tube  of  prepuce  is  drawn  through  the  tunnel  and  sutured  Avhere  it  enters 
the  glans  and  also  where  it  emerges.  At  the  end  of  ten  days  the  tiap  of  pedicle 
is  cut  through  close  to  the  new  meatus.  The  second  operation,  made  at  a  later 
period,  consists  of  a  perineal  opening  into  the  urethra  and  insertion  of  a  Jacobs' 
self -retaining  female  catheter;  this  is  the  least  irritating  and  can  be  left  as 
long  as  needed,  usually  from  five  to  eight  days.  An  incision  at  the  termination 
of  the  two  urethras  now  admits  of  accurate  coaptation  by  sutures,  or  the 
normal  urethra  may  be  mobilized  to  a  sufficient  extent  to  admit  of  its  insertion 
into  the  caliber  of  the  new  urethra,  where  it  is  held  by  sutures  and  the  external 
parts  closed  over  this.  Occasionally  a  little  urine  escapes  into  the  urethra  and 
the  entire  canal  is  best  drained  by  passing  several  silk-worm  strands  of  horse- 
hair through  the  urethra  and  out  alongside  the  catheter  in  the  perineal  open- 
ing. When  union  of  the  canals  is  complete  the  drains  are  removed  and  the 
perineal  draina,ge  will  usually  close  itself  in  a  few  days.  Horsehair  and  fine 
catgut  have  proved  the  best  suture  material  for  this  form  of  plastic  work. 
Advantages.     The  advantages  of  this  combined  operation  are : 

1.  A  urethral  tube  of  thin,  elastic  skin,  nearly  approaching  mucous  mem- 
brane, yet  having  no  hair  surface  to  occasion  later  complications. 

In  performing  this  operation  it  is  especially  important  to  bear  in  mind  the 
following  point :  A  sufficiently  large  fiap  must  be  made  to  provide  a  urethra 
that  will  reach  without  tension. 

2.  The  trocar  opening  through  the  body  of  the  penis  must  be  very  large,  in 
fact  so  large  that  the  circulation  in  the  new  urethra  will  not  be  interfered  with 
after  the  organ  becomes  edematous. 

3.  A  perineal  drain  for  the  bladder,  with  a  self -retaining  Jacobs'  female 
catheter,  must  be  employed. 

4.  A  silkworm  drain  for  the  urethra  should  always  be  inserted. 

This  method  is  capable  of  application  to  the  worst  types  of  hypospadia 
cases. 

If  there  is  a  marked  groove  in  the  penis,  indicating  the  fact  that  the  lack 
of  closure  of  the  canal  depended  upon  a  very  small  defect,  a  method  which 
was  most  perfectly  described  and  illustrated  by  C.  H.  Mayo  will  be  found  most 
useful. 

Method  of  C.  H.  Mayo.  The  plates  (a)  show  the  original  incisions,  which 
are  not  nearly  as  far  apart  near  the  glans  penis  as  they  must  be  in  order  to 
secure  an  ample  urethra.  At  (b)  the  lower  flap  is  dissected  up,  which  is  pres- 
ently to  be  utilized  for  covering  the  urethra  formed  of  the  upper  portion.  At 
(c)  this  urethra  has  been  formed  by  suturing  the  free  edges  with  fine  catgut. 
At  (d)  the  lower  flap  has  been  sutured  upward,  twisted  180  degrees  upon  its 
pedicle  and  its  edges  have  been  sutured  to  the  edges  of  the  wound  from  which 
the  tissue  was  cut  to  form  the  urethral  canal. 

Another  equally  ingenious  method  is  shown  which  has  the  advantage  of 
not  using  long  flaps,  but  there  is  the  disadvantage  of  subjecting  the  tissues  to 
a  certain  degree  of  tension,  although  this  may  be  relieved  in  a  measure  by 
making  a  longitudinal  incision  through  the  skin  on  the  dorsal  surface  of  the 
penis  from  the  glans  to  the  pubis.  At  (e)  the  flap  is  being  cut  and  elevated  to 
produce  the  new  urethra;  at  (f)  this  is  further  developed,  showing  also  the 
perforation  of  the  glans  ;  at  (g)  the  new  urethra  has  been  covered  by  the  lateral 
flaps  and  in  order  to  relieve  the  tension  from  these  a  row  of  mattress  sutures 
has  been  applied,  because  without  these  the  line  of  suture  invariably  opens, 
(h)  represents  a  cross-section  of  the  penis  after  all  sutures  have  been  applied. 

The  mattress  sutures  are  tied  rather  loosely  over  a  fine  rubber  drainage 
tube  at  each  edge  in  order  to  allow  for  the  edema  which  always  appears. 

Still  another  method  applicable  to  cases  of  very  slight  degree,  is  shown  at 
(i),  where  the  urethra  reaches  to  the  base  of  the  glans,  or  in  cases  as  shown  at 


SURGERY  OF  THE  GENITO-URIXARY  TRACT  583 

(j)  in  which,  the  urethra  can  be  mobilized  and  brought  fonvard,  the  glans 
being  perforated  so  that  the  end  of  the  urethra  will  open  at  the  proper  point. 
In  this  operation  it  is  again  important  to  make  ample  flaps  so  that  there  will 
be  no  tension.    At  (k;  this  operation  is  shown  as  completed. 

Another  ingenious  plan  is  represented  in  the  plate  at  {Ij,  in  which  a  flap 
has  been  cut  in  the  scrotum  just  sufficient  to  make  the  inferior  lining  of  the 
urethra.  This  is  sutured  into  two  incisions,  forming  a  flap  which  will  make 
the  anterior  half  of  the  urethral  lining.  After  perfect  union  has  been  accom- 
plished this  flap  is  dissected  up,  leaving  the  urethra  closed.  The  new  surface 
formed  may  be  covered  with  a  long,  narrow,  skin  graft,  or  it  may  be  per- 
mitted to  become  covered  with  epithelium  from  the  edges. 

The  objection  to  this  method  lies  in  the  fact  that  occasionally  a  few  hairs 
will  grow  in  the  part  of  the  urethra  f.ormed  from  the  flap  taken  from  the 
scrotum,  and  the  earthy  phosphates  contained  in  the  urine  are  likely  to  collect 
on  these  hairs. 

In  many  cases  the  penis  is  curved  downward  because  of  the  shortness  of 
the  skin  and  fascia  on  the  inferior  surface.  To  overcome  this  deformity  a 
transverse  incision  may  be  made  through  all  of  the  tissues  that  bind  the  organ 
and  then  the  wound  can  be  spread  lengthwise,  as  at  (mj. 

Almost  innumerable  methods  have  been  practised,  as  suggested  by  the  con- 
ditions present  in  the  particular  case  under  consideration;  at  (oj  is  represented 
an  ingenious  plan  of  arrangement  which  prevents  the  incision  in  the  urethra, 
and  that  in  the  skin,  from  coming  opposite  each  other. 

In  all  of  these  operations  it  is  well  to  make  a  perineal  urethrotomy  through 
which  a  retention  catheter  is  inserted,  which  is  kept  in  place  until  the  wound 
has  healed.  Neglecting  to  take  this  precaution  usually,  or  at  least  frequently, 
results  in  failure. 

While  the  retention  catheter  is  in  place  it  is  important  to  give  a  small 
amount  of  aromatic  sulphuric  acid,  or  some  other  mineral  acid,  in  distilled 
water  every  two  or  three  hours  to  prevent  the  accumulation  of  earthy  phos- 
phates in  the  catheter.  The  dose  must,  of  course,  be  regulated  according  to  the 
age  of  the  patient. 

Another  precaution  which  it  is  important  to  take  into  account  in  all  of 
these  operations  is  the  fact  that  in  many  cases  a  satisfactory  ultimate  result 
can  be  obtained  much  sooner  if  the  operation  is  carried  out  in  a  number  of 
stages,  and  if  these  stages  are  not  hurried,  as  one  frequently  loses  much  that 
has  been  gained  by  a  little  too  much  haste.  One  must  also  bear  in  mind  the 
fact  that  considerable  edema  is  to  be  expected  and  that  consequently  due  al- 
lowance must  be  made  for  this  in  order  to  prevent  the  occurrence  of  pressure 
necrosis,  which  would  otherwise  result  from  the  additional  tension  caused  by 
the  edema. 

Again  the  principle  that  to  obtain  satisfactory  results  from  operations  for 
the  correction  of  deformities  we  must  overcorrect  them,  is  illustrated  strik- 
ingly in  this  operation. 

VARICOCELE 

This  condition  is  found  mostly  in  boys  above  the  age  of  sixteen. 

Classes.  There  are  three  distinct  classes  under  which  all  patients  may  be 
distributed  from  a  clinical  standpoint.  In  the  first  there  are  no  symptoms: 
the  patient  discovers  the  deformity  by  accident  or  it  is  recognized  by  his  physi- 
cian incidentalh^  In  the  second  class  the  patient  has  suffered  severely  from 
a  dragging  pain  in  the  left  side  of  the  scrotum,  extending  into  the  groin  and 
frequently  into  the  back.  This  pain  is  increased  when  the  patient  is  compelled 
to  stand  at  his  work  or  lift  heavy  weights.    It  is  also  much  more  severe  when 


584 


SURGERY  OF  THE  GENITO-URINARY  TRACT 


he  is  tired,  especially  during  warm  weather.  This  is  a  marked  feature  of  vari- 
cocele, that  the  number  of  cases  regularly-  increases  in  our  hospital  service 
with  the  approach  of  warm  weather  and  decreases  in  winter.  In  the  third 
class  the  patient  is  neurasthenic  and  has  attributed  many  forms  of  mental  and 
physical  suffering  to  the  varicocele.  He  may  suffer  physically  in  the  same 
manner  as  the  patient  in  the  second  class,  but  the  prominent  symptoms  are 
those  of  neurasthenia. 

Diagnosis.     There  is  a  marked  difference  upon  palpation  in  the  right  and 
left  half  of  the  scrotum.     On  the  right  side  can  be  distinguished  a  hard,  cord- 


Vakicocelp:  (  )i'?:katiox. 

a  vas  deferens;  b  varicose  veins  the  two  stumps  being  sutured  together  with  catgut  suture 
to  elevjite  the  testicle  in  left  side  of  the  scrotum. 


like  structure — the  vas  deferens — extending  the  entire  distance  of  the  scrotum, 
with  the  testicle  located  at  its  lower  end.  On  the  left  side  these  parts  are 
almost  concealed  by  a  large  accumulation  of  elastic,  worm-like  structures 
coiled  upon  themselves,  giving  rise  to  the  sensation  which  has  been  compared 
to  the  manipulation  of  a  number  of  angleworms.  This  is  due  to  the  great  dila- 
tation of  the  spermatic  veins,  which  are  in  a  varicose  condition. 

H  the  patient  is  placed  in  the  recumbent  position  the  veins  become  empty 
and  can  no  longer  be  felt  unless  the  affection  has  existed  for  a  long  time,  in 
which  case  the  walls  of  the  veins  themselves  will  have  become  thickened  in 
the  natural  tendency  of  compensation,  and  then  the  change  in  the  fullness  of 
the  vessels  will  not  so  completely  alter  the  impression  upon  palpation. 

Very  rarely  the  condition  is  present  upon  both  sides,  and  still  more  rarely 


SUEGERY  OF  THE  GEXITO-URIXAPvY  TRACT  585 

upon  the  right  side  alone,  because  the  anatomical  difference  of  the  two  sides 
lavors  the  tormation  of  varicocele  upon  the  left. 

The  malady  is  so  characteristic  that  it  is  not  likely  to  ever  be  confounded 
with  any  other. 

Indications  for  operation.  In  the  first  class  operation  is  plainly  not 
indicated,  as  in  itself  tne  condition  is  harmless  so  long  as  it  gives  rise  to  neither 
pain  nor  discomfort.  It  neither  causes  any  other  patnoiogical  state  nor  does  it 
predispose  to  any;  hence  there  can  be  no  good  reason  for  surgical  procedure. 
in  these  cases  it  may  be  proper  to  advise  tiie  wearing  of  a  weii-litting  suspen- 
sory bandage,  which  will  tend  to  prevent  the  further  dilatation  of  tlie  veins. 

In  the  second  class  surgical  treatment  is  strongly  indicated,  because,  if 
properly  executed,  it  will  result  in  permanent  relief  m  almost  every  case.  It 
can  be  performed  with  safety  to  the  patient,  and  it  will  disable  him  from  work 
only  for  a  short  time. 

In  the  third  class  it  is  necessary  to  determine  whether  there  is  any  pos- 
sibility of  causal  relation  between  the  varicocele  and  the  neurasthenia,  if 
such  a  relation  can  be  established  the  operation  is  plainly  indicated,  if  there 
is  as  plainly  no  relation  between  the  two,  then  the  operation  is  not  called  for 
unless  there  seems  to  be  reason  to  suppose  that  the  presence  of  the  deformity 
causes  undue  anxiety  of  the  patient,  which  in  turn  causes  or  increases  his 
neurasthenia.  In  such  event  the  removal  of  the  deformity  might  remove  at 
least  one  cause  of  the  neurasthenia. 

If  there  is  doubt  it  seems  but  fair  that  the  patient  be  given  the  benefit 
thereof,  and  that  surgical  relief  of  the  pathological  condition  be  employed. 

Technique.  An  incision  three  to  four  centimeters  in  length  is  made  di- 
rectly over  the  spermatic  cord  downward  from  a  point  just  below  the  external 
abdominal  ring.  The  blood  vessels  which  appear  in  the  incision  are  either 
caught  at  once  between  two  pairs  of  hemostatic  forceps  and  then  cut,  or  the 
incision  is  made  directly  down  to  the  tissues  of  the  spermatic  cord  and  the 
bleeding  points  thus  caught  with  hemostatic  forceps. 

It  is  important  that  throughout  this  operation  all  bleeding  be  carefully  con- 
trolled, in  order  to  prevent  infiltration  of  the  tissues  with  blood  or  the  forma- 
tion of  a  hematoma,  for  both  of  these  states  are  exceedingly  annoying,  not  so 
much  on  account  of  their  inlierent  importance  as  because  of  the  anxiety  they 
produce  in  the  patient. 

The  cord  is  then  brought  up  into  the  wound  and  the  vas  deferens,  with  a 
few  of  the  accompanying  small  arteries  and  veins,  isolated.  This  leaves  the 
great  mass  of  varicose  veins  in  a  separate  bunch.  After  carefully  carryiug 
this  separation  from  the  external  abdominal  ring  to  a  point  half  an  inch  from 
the  testicle,  the  m.ass  of  veins  is  transfixed  above  and  below  with  a  double 
catgut  ligature  and  tied  in  halves.  The  intervening  portion  is  then  cut  away, 
caution  being  taken  to  leave  a  sufficient  amount  of  tissue  beyond  the  ligatures 
to  prevent  slipping.  The  two  stumps  are  then  united  with  catgut  sutures  to 
prevent  the  dragging  down  of  the  testicle,  with  its  subsequent  discomfort. 

There  is  some  danger  of  shortening  the  cord  too  much  sc  that  the  testicle 
will  be  drawn  up  close  to  the  external  abdominal  ring.  This  does  not  give 
rise  to  any  pain,  but  the  deformity  may  cause  an  increase  in  the  neurasthenic 
condition  of  the  patient.  If  possible  the  testicle  on  the  operated  side  should 
hang  only  a  little  higher  than  the  opposite  one.  It  is  quite  important  to  have 
the  result  both  cosmetically  and  anatomically  as  nearly  perfect  as  possible. 

The  deep  fascia  is  then  sutured  with  fine  catgut,  and  later  the  skin.  It 
seems  best  to  suture  the  fascia  separately  in  order  to  prevent  the  infection  of 
the  deep  tissues  from  the  skin.  An  ordinary  gauze  dressing  is  applied  to  the 
wound  and  held  in  place  by  a  suspensory  bandage.  The  wound  usually  heals 
within  a  week,  and  the  patient  is  able  to  perform  ordinary  work  in  two  weeks. 


586 


SURGERY  OF  THE  GENITOURINARY  TRACT 


This  is  a  very  satisfactory  operation  as  a  rule,  because  it  is  tlioroughly  appre- 
ciated by  the  patient. 

If  one  approaches  the  testicle  too  closely  in  the  operation  the  resulting  irri- 
tation is  likely  to  cause  the  formation  of  a  hydrocele.  In  order  to  prevent  this 
in  any  case  in  which  there  seems  such  a  likelihood,  it  is  best  to  split  the  tunica 
vaginalis,  evert  it  and  suture  it  in  the  everted  position  before  replacing  the 
testicle  in  the  scrotum.  In  cases  in  which  this  has  not  been  done,  and  in  which 
a  hydrocele  does  occur  after  a  varicocele  operation,  the  injection  method  for 
the  treatment  of  hydrocele  (to  be  described  directly)  usually  gives  immediate 
and  permanent  relief. 

HYDROCELE 

This  may  affect  either  the  tunica  vaginalis  of  the  testicle,  or  of  the  sper- 
matic cord,  or  both. 

The  change  is  usually  attributed  to  an  acute  trauma,  or  there  may  have 
existed  an  orchitis  due  to  a  specific  urethritis.     The  physician  is  usually  not 


\ 

X 

fe^ 

j.« 

m^^f'^ 

r  ■ 

Hydrocele. 


consulted  until  the  tumor  has  attained  so  great  a  size  that  its  weight  gives 
rise  to  discomfort,  and  it  may  annoy  the  patient  on  account  of  the  deformity, 
or  it  may  interfere  with  locomotion.  It  is  usuall}^,  but  not  always,  uni- 
lateral. 

Diagnosis.  Aside  from  the  rare  occurrence  of  sarcoma  so  soft  in  structure 
as  to  simulate  fluctuation,  the  only  condition  with  which  hydrocele  can  be 
confounded  is  scrotal  hernia.  This  is  true  especially  in  children  in  whom  the 
contents  of  a  hernia  frequently  give  the  same  impression  on  palpation  as  the 
liquid  contained  in  a  hydrocele.  This  is  especially  true  in  hydrocele  of  the 
cord,  which  is  located  in  the  lower  end  of  the  inguinal  canal  and  which  can 
frequently  be  reduced  through  the  inguinal  canal  into  the  peritoneal  cavity. 
There  is,  however,  this  difference,  viz.,  hydrocele  will  always  reduce  as  a 
solid  mass,  only  to  reappear  in  a  few  moments  without  regard  to  the  form 


SUEGERY  OF  THE  GENITO-URINAEY  TRACT 


587 


of  truss  that  may  be  applied,  while  hernia  will  give  the  sensation  of  being 
composed  of  loose  substance,  and  it  will  remain  reduced  if  properly  supported 
by  a  truss. 

In  hydrocele  of  the  tunica  vaginalis  the  light  test  is  the  most  reliable.  A 
small  tube  is  applied  to  the  side  of  the  scrotum,  then  a  light  is  placed  upon 
the  opposite  side.  If  the  light  is  seen  through  the  tube  it  is  an  indication  that 
the  mass  is  composed  of  a  sac  containing  transparent  fluid.  However,  it 
sometimes  happens  that  the  hydrocele  is  so  thick-walled  in  old  patients  that 
no  light  will  penetrate.     Occasionally  the  fluid  may  not  be  transparent,  being 


Hydrocele  of  the  Cord  and  Varicocele. 

The  upper  mass  (A)  is  the  hydrocele,  the  middle  (B)  the  varicocele,  and  the  lower  (C)  the 
testicle.    Treatment — excision  of  the  sac  and  4/5  of  the  veins. 


discolored  by  blood  pigments,  and  then  the  light  test  may  be  misleading.  A 
very  simple  test  consists  in  grasping  the  scrotum,  directly  above  the  mass, 
between  the  finger  and  thumb.  If  the  tissues  of  the  cord  can  be  plainly  dis- 
tinguished the  case  is  one  of  hydrocele ;  if  not,  it  is  a  hernia. 

Abscesses  may  be  distinguished  by  the  evidence  of  inflammation;  edema 
of  the  scrotum,  because  of  edema  elsewhere  in  the  body.  Tumors  of  the  testicle 
are  usually  hard,  and  do  not  fluctuate. 

Occasionally  in  old  patients  in  whom  the  hydrocele  has  existed  for  a  long 
time,  especially  if  it  has  been  frequently  tapped,  the  walls  of  the  cyst  undergo 
calcareous  degeneration,  giving  the  impression  of  a  hard  tumor.  This  has 
repeatedly  been  mistaken  for  sarcoma  or  enchondroma,  a  mistake  which  is 
quite  unfortunate,  because  it  is  usually  not  discovered  until  after  the  organ 
has  been  removed. 

Technique  in  children.  In  children  simple  tapping  will  suffice  to  bring 
about  a  permanent  cure.  This  may  be  repeated  a  few  times  if  necessary,  and 
if  not  permanently  successful  it  should  be  followed  by  the  injection  into  the 


588  SURGERY  OF  THE  GENITO-URINARY  TRACT 

sac,  after  the  latter  has  been  very  carefully  emptied,  of  a  few  drops  of  ninety- 
live  per  cent,  carbolic  acid.  The  canula  of  the  trocar  should  be  closed  and 
left  in  place  while  the  carbolic  acid  is  distributed  over  the  entire  surface  by 
carefully  massaging  the  scrotum.  After  a  few  minutes  the  canula  should  be 
opened,  and  whatever  fluid  may  have  again  accumulated,  together  with  the 
carbolic  acid,  should  be  drawn  off.  In  small  children  five  drops  of  a  thirty 
per  cent,  solution  of  carbolic  acid  in  glycerine  will  suffice,  if  the  sac  has  been 
carefully  emptied  before  this  fluid  is  injected.  It  does  not  matter  if  all  of  this 
fluid  remains  in  the  sac,  as  the  amount  is  not  sufficient  to  cause  symptoms  of 
poisoning  from  absorption. 

During  the   entire  manipulation  the  external  abdominal  ring  should  be 
compressed,  in  order  to  prevent  the  introduction  into  the  peritoneal  cavity  of 


Encysted  Hydrocele  of  the  Cord  Extending  Upwards  and  Forming  a  Large  Tumor  in  the 
Abdomen,     a,  Upper  Limit  of  Abdominal   Tumor. 


any  portion  of  the  carbolic  acid,  in  case  the  upper  end  of  the  tunica  vaginalis 
has  not  yet  become  entirely  closed. 

In  hydrocele  of  the  cord  in  children  tapping  alone  almost  always  suffices. 
If  this  is  not  the  case,  it  is  well  to  make  a  longitudinal  incision,  opening  the 
hydrocele  and  tamponing  the  cavity  with  iodoform  gauze.  After  a  few  days 
the  gauze  may  be  removed  and  the  wound  will  heal  completely  in  a  short 
time.  It  does  not  matter  that  the  inguinal  canal  is  thus  left  wide  open  after 
the  hydrocele  of  the  cord  which  closed  it  has  been  emptied  and  can  conse- 
quently no  longer  act  as  a  plug.  During  the  short  period  that  the  child  will 
be  compelled  to  remain  in  the  recumbent  position  the  canal  Avill  contract  suffi- 
ciently to  prevent  the  protrusion  of  a  hernia. 

Technique  in  adults.  If  the  patient  can  conveniently  abandon  his  work 
for  one  or  two  weeks,  it  is  usually  best  to  advise  the  operation  for  radical  cure, 
to  be  described  presently.  If  he  cannot  leave  his  work  and  desires  only  tem- 
porary relief,  tapping  will  accomplish  this.  If  he  cannot  remain  away  from 
his  work,  but  still  desires  to  obtain  some  hope  of  a  permanent  cure,  without  a 
certainty,  it  may  be  well  to  make  use  of  the  ninety-five  per  cent,  carbolic 


SUKGERY  OF  THE  GENITO-URINARY  TRACT 


589 


acid,  just  mentioned,  with  a  change  in  the  quantity  to  be  employed.  After 
aspirating  the  fluid,  from  one  to  two  drachms  of  ninety-five  per  cent,  car- 
bolic acid  is  injected  and  forced  into  contact  with  every  portion  of  the  lining 
of  the  sac  by  massage.  The  acid  should  be  left  in  contact  with  the  surface 
for  at  least  five  minutes,  then  it  should  be  forced  out  through  the  canula, 
which,  of  course,  has  in  the  meantime  been  kept  closed.  The  patient  should 
then  be  put  to  bed  for  a  few  hours,  after  which  he  may  resume  his  occupa- 
tion. In  our  own  practice  we  have  frequently  applied  this  treatment  on 
Saturday  evening,  and  the  patient  has  always  been  able  to  resume  work  with 
perfect  comfort  on  Monday  morning. 

In  about  one-half  of  all  the  cases  this  method  will  result  in  a  permanent 


The  Wyllts  Andrews  Method. 


cure,  and  it  is  worth  while  to  explain  to  each  patient  coming  for  treatment 
the  first  time,  that  in  about  one-half  the  cases  this  simple  method  will  accom- 
plish everything  he  may  desire.  The  method  has  the  further  advantage  of 
being  painless.  Recently  we  have  followed  the  plan  practised  by  Coley  of 
completely  aspirating  the  fluid  contained  in  the  hydrocele  and  then  injecting 
five  drops  of  a  ninety-five  per  cent,  solution  of  carbolic  acid,  or  fifteen  drops 
of  a  thirty  per  cent,  solution  in  glycerine,  and  leaving  this  in  the  sac.  The 
proportion  of  cures  seems  to  be  about  equal  to  that  just  described. 

Radical  operation.  An  incision,  one  and  one-half  inches  in  length,  is  made 
over  the  anterior  surface  of  the  side  of  the  scrotum  involved,  directly  down 
through  the  tunica  vaginalis,  which  will  permit  the  fluid  to  escape.  The  inner 
surface  of  the  sac  and  the  surface  of  the  testicle  are  carefully  inspected  in 
order  to  detect  any  tubercles  which  might  account  for  the  accumulation  of 
fluid.  If  present  they  are  carefully  removed,  preferably  with  the  knife  of 
an  electro-cautery.  If  none  are  found  the  tunica  vaginalis  is  everted  over  the 
testicle  and  held  by  a  few  stitches  of  catgut ;  then  the  testicle,  together  with 
its  everted  tunica  vaginalis,  is  replaced  in  the  scrotum.     Great  care  is  exer- 


590  SURGERY  OF  THE  GENITO-URINARY  TRACT 

cised  to  secure  absolutely  perfect  hemostasis  so  as  to  prevent  any  accumula- 
tion of  blood  in  the  scrotum  after  the  operation.  The  deep  fascia  is  first  sutured 
with  catgut  and  then  the  skin  is  united.  An  ordinary  dressing  is  applied  and 
held  in  place  by  a  suspensory  bandage. 

It  is  very  important  to  inspect  the  testicle  carefully  in  order  to  discover 
Rny  small  cysts  which  may  be  present  on  the  surface,  either  because  of  the 
adhesion  of  a  portion  of  the  tunica  vaginalis,  or  of  accumulation  of  serum 
underneath  the  portion  of  this  structure  covering  the  testicle.  In  either  event 
the  anterior  layer  of  tunica  vaginalis  is  cut  away  entirely  in  order  to  exclude 
the  possibility  of  a  recurrence. 

The  wound  heals  in  a  few  days,  and  in  a  week  the  patient  is  able  to  follow 
his  usual  labor.  The  operation  is  so  simple,  safe  and  satisfactory  in  its  re- 
sults that  it  seems  foolish  for  one  to  carry  a  hydrocele  about  for  years  and  go 
through  the  annoyance  of  repeated  tappings  when  he  might  in  a  few  days 
obtain  permanent  and  perfect  relief. 

CYSTOTOMY 

During  the  past  few  years  it  has  become  an  almost  universal  practice  to 
open  the  bladder  through  a  suprapubic  incision  for  the  removal  of  stones  and 
foreign  growths,  and  for  permanent  drainage  of  the  bladder  from  any  cause. 
The  operation  in  itself  is  relatively  simple. 

Preparatory  treatment.  Before  undertaking  any  operation  upon  the  blad- 
der it  is  desirable  that  the  urine  should  be  as  nearly  aseptic  as  possible.  Meas- 
ures should  be  taken  to  make  the  urine  as  nearly  normal  as  the  conditions 
of  the  patient  will  permit.  That  affection  for  which  the  operation  is  required 
usually  predisposes  to  an  abnormal  state  of  the  urine,  and  frequently  not  onl}'- 
the  bladder,  but  also  the  kidneys  are  diseased.  If  the  urine  contains  septic 
material  this  may  be  changed  by  dilution,  the  patient  being  given  large  quan- 
tities of  distilled  water,  or,  if  this  is  not  agreeable,  one  of  the  various  mineral 
waters  in  large  quantities.  Such  course  will  reduce  the  septic  character  of  the 
urine  to  a  great  extent.  If  the  urethra  is  permeable  to  the  passage  of  a  cathe- 
ter, irrigation  of  the  bladder  with  a  mild,  non-irritating  antiseptic  solution, 
such  as  boric  acid ;  1  to  1,000  solution  of  permanganate  of  potash ;  1  to  2,000 
solution  of  nitrate  of  silver;  a  saturated  solution  of  acetate  of  aluminum;  or  a 
solution  of  any  one  of  a  number  of  recently  produced  silver  salts,  may  be  used. 
These  silver  salts  have  the  advantage  of  not  being  precipitated  by  contact 
with  urine.  These  solutions  may  be  used  in  from  one  to  ten  per  cent,  strength, 
and  from  one  to  two  ounces  may  be  safely  left  in  the  bladder  after  conclu- 
sion of  the  irrigation.  If  a  solution  of  nitrate  of  silver  is  used  the  bladder 
should  first  be  irrigated  repeatedly  with  distilled  or  boiled  water,  as  other- 
wise all  of  the  silver  will  at  once  be  made  useless  by  being  precipitated  in  the 
form  of  silver  chloride.  Adding  an  ounce  of  strong  alcohol  to  a  pint  of  sat- 
urated solution  of  boric  acid  makes  one  of  the  best  solutions  for  irrigation. 

Care  should  be  taken  not  to  irritate  the  bladder  with  any  of  these  solu- 
tions. If  it  is  found  that  one  irritates  more  than  the  other  it  should  be  avoided. 
The  bladder  should  be  filled  moderately  full  and  then  the  fluid  permitted  to 
escape,  or  the  bladder  may  be  irrigated  with  a  constant  stream  through  a 
double  catheter,  one  tube  serving  the  purpose  of  introducing  the  fluid,  the 
other  of  emptying  the  bladder.  A  repeated  examination  of  the  urine  will 
determine  whether  this  treatment  reduces  the  amount  of  septic  material 
regularly  found. 

There  are  a  number  of  antiseptics  that  may  be  given  internally  as  urinary 
disinfectants.  Of  these  five  grain  doses  of  boric  acid  given  with  half  a  pint 
of  distilled  water,  or  mineral  water,  every  three  hours ;  the  same  dose  of  salol, 


SUEGERY  OF  THE  GENITO-URINARY  TRACT  591 

or  of  iirotropin;  or  one-grain  doses  of  methylene-blue  given  in  the  same 
manner,  are  probably  the  most  useful.  There  is,  however,  this  fact  to  remem- 
ber, that  urine  usually  is  most  septic  if  the  bladder  is  not  at  any  time  com- 
pletely evacuated,  and  consequently  but  a  slight  amount  of  benefit  is  to  be 
expected  unless  the  residual  urine  is  removed  once  or  twice,  or  oftener,  each 
day,  and  the  bladder  carefully  irrigated. 

Irrigation.  Just  before  the  operation  the  bladder  should  again  be  carefully 
and  repeatedly  irrigated  so  that  any  accumulation  of  septic  material  may  be 
thoroughly  washed  away  and  any  remnants  that  cannot  be  so  washed  away 
may  be  thoroughly  diluted.  In  many  cases  the  bladder  contains  weakened 
points  and  consequently  great  care  should  be  used  in  this  final  irrigation,  which 
is  usually  performed  after  the  patient  has  been  anesthetized,  not  to  fill  the  blad- 
der with  too  much  force  for  fear  of  causing  a  rupture  at  some  frail  point. 
After  this  irrigation  has  been  completed  the  bladder  should  be  filled  moderately 
either  with  air  or  water.  The  latter  may  be  injected  through  a  catheter  by 
means  of  an  ordinary  bulb  syringe,  not  more  than  eight  ounces  being  intro- 
duced. The  quantity  can  be  measured  by  the  size  of  the  bulb  used.  In  case 
air  is  used,  it  is  best  to  leave  the  catheter  in  place  after  the  bladder  has  been 
irrigated  and  to  attach  it  by  means  of  a  glass  tube  to  a  rubber  bulb.  The 
incision  is  then  made  through  all  the  tissues  down  to  fat  in  the  space  of 
(Retzius.  Then  the  bladder  is  pumped  full  of  air  and  it  can  be  observed  as  it 
expands  in  the  depths  of  the  wound. 

Technique.  Many  surgeons  prefer  to  make  a  transverse  incision  just  above 
the  pubic  bone,  down  to  the  aponeurosis  of  the  recti  muscles,  and  then  to  cut 
longitudinally  between  these  muscles.  We  have  made  this  incision,  as  well 
as  the  longitudinal  one  about  to  be  described,  and  have  found  both  equally 
satisfactory. 

The  field  of  operation  has,  of  course,  been  carefully  shaved  and  prepared ; 
then  a  longitudinal  incision  is  made  in  the  median  line  directly  upwards  from 
the  OS  pubis,  a  distance  of  five  centimeters.  The  muscles  are  separated  and 
the  fat  above  the  pubis  and  front  of  the  bladder  exposed.  This  contains  a 
number  of  veins  of  considerable  size  which  usually  extend  transversely  or 
obliquely  across  the  incision.  They  should  be  grasped  with  hemostatic  forceps 
on  either  side,  cut  and  ligated  at  once.  The  wound  is  carried  through  the 
fat  down  to  the  wall  of  the  bladder.  In  making  this  dissection  great  care 
should  be  taken  not  to  extend  the  incision  too  high  for  fear  of  entering  the 
peritoneal  cavity.  This  is  not  likely  to  occur,  however,  if  the  bladder  is  filled 
with  water  or  air,  unless  the  viscus  is  pendulous  and  displaced  backwards.  In 
such  event  the  peritoneum  may  approach  the  os  pubis  and  may  have  to  be 
shoved  upwards  and  held  out  of  the  path  of  operation  by  means  of  retractors. 
A  suture  is  then  applied  to  the  wall  of  the  bladder  in  the  upper  angle  of  the 
wound  for  the  purpose  of  securing  it  against  separation  from  the  anterior 
abdominal  wall.  Two  other  stitches  are  applied  in  the  bladder  wall  with  curved 
needles  one  centimeter  to  each  side  of  the  median  line.  Forceps  should  be 
applied  to  each  one  of  these  stitches,  and  the  bladder  wall  drawn  forward 
gently.  A  longitudinal  incision  is  then  made,  from  one  to  three  centimeters 
in  length,  according  to  the  object  of  the  cystotomy,  and  the  edges  of  the 
wound  grasped  with  fine-toothed  forceps  and  held  open  while  the  interior 
of  the  bladder  is  being  exposed.  As  soon  as  this  incision  is  made  the  fluid 
(or  air)  contained  in  the  bladder  will  escape  and  the  bladder  walls  begin  to 
contract.  If  a  stone  is  present  its  size  may  be  determined  and  the  incision 
in  the  bladder  wall  increased  if  necessary.  The  position  of  the  stone  is  deter- 
mined with  the  finger,  and  it  is  grasped  by  means  of  stone  forceps  in  its 
narrowest  diameter  and  withdrawn  from  the  wound  in  the  bladder  with  the 
gentlest  possible  motion.     The  interior  of  the  bladder  should  then  again  be 


592  SURGERY  OF  THE  GENITO-URINARY  TRACT 

examined  for  further  stones,  and  this  should  be  repeated  until  all  such  have 
been  removed.  If  a  tumor  is  present  an  assistant  should  introduce  two  or  three 
fingers  into  the  rectum  and  force  the  tumor  toward  the  wound  so  as  to  facili- 
tate its  examination  and  removal. 

The  method  of  removal  of  a  tumor  will  depend  largely  upon  its  size  and 
location,  and  must  be  determined  upon  general  principles  in  each  case. 

If  the  operation  has  been  undertaken  for  the  purpose  of  securing  per- 
manent drainage,  the  incision  should  be  made  as  near  the  os  pubis  as  possible, 
and  be  only  just  large  enough  for  the- purpose  of  permitting  careful  digital 
exploration.  Several  purse-string  sutures  should  then  be  applied  to  prevent 
leakage,  and  a  retention  catheter  introduced.  The  wound  should  be  tamponed 
around  this  retention  catheter  and  the  stitches  in  the  bladder  wall  passed 
through  the  edge  of  the  wound  and  tied  just  sufficiently  tight  to  hold  the 
anterior  wall  in  close  apposition  with  the  abdominal  wall.  A  few  silkworm 
gut  sutures  are  then  applied,  so  as  to  grasp  the  wound  on  each  side,  and  to 
take  a  small  bite  in  the  anterior  wall  of  the  bladder  above  the  point  of  inci- 
sion, and  two  small  bites,  one  on  each  side  of  the  incision  in  this  portion  of  the 
bladder.  These  sutures  are  left  untied  until  the  first  dressing,  which  occurs  a 
few  days  after  the  operation,  when  the  gauze  tampon  and  the  three  first 
stitches  may  be  removed  and  the  silkworm  sutures  may  be  tied,  leaving  only  a 
space  open  through  which  the  drainage  tube  passes.  If  the  bladder  has  been 
in  a  septic  condition,  it  is  often  best  to  pass  two  ordinary  rubber  drainage 
tubes  one-half  a  centimeter  in  diameter,  perforated  with  several  small  open- 
ings in  the  end.  It  is  then  possible  to  irrigate  the  bladder  by  permitting  the 
fluid  to  flow  in  through  one  of  these  tubes  and  out  of  the  other ;  and  in  case 
one  or  the  other  becomes  occluded  with  mucus  or  blood  the  free  one  will 
suffice  to  drain. 

After-treatment.  The  most  important  point  in  the  after-treatment  consists 
in  giving  the  patient  large  quantities  of  pure  water  to  drink.  If  the  patient 
is  at  all  shocked  by  the  operation  it  is  wise  to  give  him  a  saline  transfusion 
at  once,  or  to  give  him  an  enema  of  half  a  pint  of  normal  salt  solution  every 
hour. 

It  is  well  to  give  the  patient  from  two  to  five  drops  of  dilute  aromatic  sul- 
phuric acid  in  half  a  pint  of  distilled  water  every  hour  during  the  day,  and 
every  two  to  three  hours  during  the  night.  This  will  prevent  the  accumula- 
tion of  earthy  phosphates  in  the  bladder  or  in  the  drainage  tubes. 

The  bladder  should  be  irrigated  with  a  saturated  solution  of  boric  acid 
from  two  to  six  times  a  day,  according  to  the  character  of  the  urine.  If  two 
rubber  tubes  are  employed,  sufficiently  long  for  the  ends  to  project  into  an 
antiseptic  solution  in  a  bottle  tied  to  the  side  of  the  bed,  the  patient  will 
usually  remain  perfectly  dry.  It  is  a  good  plan  to  insert  a  glass  tube  into 
the  end  of  the  rubber  tube,  so  that  its  weight  will  keep  it  from  becoming 
dislodged  from  the  bottle.  By  placing  a  Y-shaped  glass  tube  in  the  course 
of  the  tube  leading  from  the  bladder  to  the  bottle,  and  having  one  of  the 
short  legs  of  the  Y  attached  to  the  tube  coming  from  a  fountain  syringe 
suspended  from  a  point  higher  than  the  bed,  from  which  water  is  permitted 
to  drop  constantly,  the  rubber  tube  will  act  as  a  syphon  and  this  will  serve 
to  keep  the  bladder  empty  and  the  patient  dry.  If"  the  rubber  tubes  give 
rise  to  pain  their  position  should  be  changed  occasionally.  The  bladder 
contracts  and  then  these  tubes  cause  irritation  by  pressing  upon  the  posterior 
wall  of  the  organ. 

If  the  operation  is  done  for  the  removal  of  a  stone  from  a  healthy  blad- 
der containing  nearly  normal  acid  urine  the  wound  in  the  bladder  may  be 
closed  by  a  double  row  of  catgut  sutures,  which  are  not  permitted  to  penetrate 
the  mucous  membrane,  however.     The  space  between  the  bladder  and  the 


SURGERY  OF  THE  GENITO-URINARY  TRACT  593 

abdominal  wall  should  always  be  drained  thoroughly  in  these  cases  for  fear 
of  extravasation  of  urine.  A  soft  rubber  retention  catheter  is  placed  into  the 
bladder  through  the  urethra  in  such  instances  and  carefully  fastened  in  place, 
so  as  to  keep  the  bladder  thoroughly  drained.  If  there  is  any  doubt  about  the 
septic  condition  of  the  bladder  it  does  not  seem  wise  to  close  its  wall  completely. 
If  the  operation  is  performed  for  the  purpose  of  securing  permanent  drain- 
age, the  smaller  the  opening  in  the  bladder  the  better  will  the  operation  serve 
its  purpose.  In  these  cases  it  is  well  to  make  the  bladder  opening  as  near  the 
urethral  opening  as  possible.  If  a  permanent  drainage  is  employed,  the  bladder 
should  be  irrigated  at  least  once  a  day  with  some  mild  antiseptic  solution,  and 
it  is  advantageous  to  change  the  character  of  this  solution  repeatedly,  because 
an  occasional  change  will  increase  the  usefulness  of  any  of  the  various  anti- 
septic solutions  which  have  been  mentioned  in  this  connection. 

TUMORS  OF  THE  BLADDER 

In  the  removal  of  tumors  of  the  bladder  it  is  important  to  have  a  free  view 
of  the  field  of  operation.  This  is  secured  by  placing  the  patient  in  the  exag- 
gerated Trendelenburg  position  and  making  a  median  abdominal  section, 
extending  from  the  pubis  to  the  umbilicus,  and  tamponing  all  of  the  intestines 
and  the  omentum  out  of  the  way  into  the  upper  portion  of  the  abdominal 
cavity.  The  bladder  has  of  course  been  previously  thoroughly  irrigated,  as 
before  described,  and  is  either  entirely  empty  or  moderately  distended  with  air. 

It  is  usually  well  to  place  these  patients  on  a  diet  of  milk  and  egg  albumen 
for  a  few  days  before  the  operation  and  give  them  capsules  of  ten  grains  of 
gallic  acid  every  two  hours  for  one  or  two  days  before  the  operation,  which 
will  serve  to  reduce  the  hemorrhage  greatly.  This  of  course  is  not  necessary 
but  is  of  advantage. 

The  pelvic  cavity  behind  the  bladder  is  filled  with  a  gauze  tampon  to  catch 
any  slight  amount  of  urine  and  blood.  The  wall  of  the  bladder  is  then  caught 
with  fine-toothed  forceps  and  incised.  AA'hatever  urine  may  be  present  is 
carefully  sponged  away.  Then  the  tumor  is  excised  freely.  If  it  includes  a 
ureter  the  latter  is  picked  up  and  implanted  into  the  bladder  wall  later,  accord- 
ing to  the  method  already  described.  If  neither  the  ureter  nor  the  osteum 
of  one  or  both  ureters  is  involved,  then  the  bladder  wall  is  sutured.  The  first 
row  of  stitches  is  made  of  fine  chromic  catgut,  preferably  used  double.  This 
is  applied  after  the  manner  of  the  Connell  suture  in  intestinal  surgery,  which 
has  been  described  and  illustrated  elsewhere  herein.  A  second  row  of  sutures 
is  passed  over  this  after  the  manner  of  the  Lembert  suture  in  intestinal  surgery. 
This  may  be  done  with  a  fine,  ten-day  catgut,  or  with  silk  or  linen.  It  is  not 
necessary  to  apply  drainage,  either  to  the  bladder  wound  or  the  cavity  of  the 
bladder;  a  retention  catheter  is  likely  to  cause  more  harm  than  good. 

If  the  ureters  are  involved,  to  an  extent  making  an  implantation  into  the 
bladder  impossible  the  case  is  usually  hopeless,  but  it  may  be  worth  while 
to  make  an  oblique  implantation  into  the  colon  according  to  the  method  pre- 
viously described. 

URETHROTOMY 

Indications.  In  urethral  strictures  which  cannot  comfortably  be  kept  open 
by  means  of  bougies  passed  regularly  by  the  physician,  or  in  this  condition 
accompanied  by  a  constant  or  interrupted  discharge,  or  in  the  presence  of  pain, 
or  other  abnormal  conditions  which  can  be  attributed  to  a  stricture,  the  latter 
should  be  thoroughly  divided.     This  is  true  even  in  cases  in  which  annoying 


594  SUKGERY  OF  THE  GENITO-URINARY  TRACT 

nervous  symptoms  referable  to  strictures  persist  where  it  is  possible  to  pass 
a  sound  of  normal  size. 

These  patients  usually  give  the  history  of  one  or  more  attacks  of  gonor- 
rheal urethritis,  followed  in  time  by  an  obstruction  to  the  flow  of  urine,  which 
may  be  only  slight  or  almost  complete.  During  the  entire  time  there  may  have 
been  a  certain  amount  of  urethral  discharge,  possibly  only  a  drop  in  the  morn- 
ing. This  may  be  associated  with  an  irritable  bladder,  which  refuses  to  retain 
urine  for  the  normal  period  of  time.  There  may  be  a  sensation  of  scalding 
during  micturition. 

Diagnosis.  The  urethra  should  be  thoroughly  irrigated  with  a  saturated 
solution  of  boric  acid,  or  a  solution  of  1  to  1,000  permanganate  of  potash,  before 
an  instrumental  examination  is  made.  If  time  permits,  it  is  wise  to  give  from 
five  to  ten  grain  doses  of  boric  acid  or  salol,  or  both,  from  three  to  six 
times  a  day,  with  half  a  pint  or  more  of  pure  water,  preferably  hot,  for  several 
days.  This  will  have  a  tendency  to  disinfect  the  bladder  and  the  urethra. 
In  many  cases  it  is  wise  to  give  five-grain  doses  of  quinine  with  a  pint  of  hot 
water,  three  times  a  day,  for  one  or  two  days  before  attempting  an  instrumental 
examination  of  the  urethra.  Many  patients  who  have  repeatedly  suffered  from 
severe  sepsis,  characterized  by  a  chill  known  as  "urethral,"  followed  by  severe 
fever,  after  an  instrumental  examination,  have  remained  entirely  free  from 
these  symptoms  after  future  examinations  of  the  same  character  if  preceded 
by  the  use  of  quinine.  The  same  is  true  regarding  the  gradual  dilatation  of 
the  urethra  by  means  of  hard  rubber  bougies  or  steel  sounds. 

After  the  necessary  preliminary  preparation  a  moderate-sized  urethral 
sound,  lubricated  with  some  sterile  oily  substance,  is  introduced  with  great 
care  to  the  prostatic  urethra,  but  not  through  it.  If  this  sound  encounters 
any  obstruction  a  smaller  one  is  used  and  the  size  reduced  successively  until 
a  very  small  sound  is  tried.  The  smaller  the  sound,  however,  the  greater  must 
be  the  care  in  its  introduction,  and  whether  the  sound  be  large  or  small  it 
must  always  be  inserted  absolutely  without  force,  for  fear  of  doing  injury  to 
the  delicate  structure  of  the  canal.  If  the  original  sound  passes  to  the  pro- 
static urethra,  then  successive  sounds  are  introduced  until  the  largest  one 
has  been  secured  that  can  be  freely  passed. 

If  any  one  of  the  sounds  used  meets  an  obstruction  it  is  withdrawn  and 
the  depth  of  the  obstruction  carefully  noted ;  also  the  size  of  the  largest  sound 
which  will  just  pass  this  obstruction. 

Internal  urethrotomy.  The  urethra  is  next  examined  by  means  of  a  bulbed 
sound,  the  bulb  having  approximately  the  shape  of  an  olive.  These  sounds 
are  introduced  in  successive  sizes  until  one  is  reached  which  w^ll  just  pass 
the  constriction.  It  is  then  passed  on  and  may  possibly  encounter  further 
constrictions,  which  it  may  or  may  not  pass.  If  a  smaller  constriction  is 
encountered,  smaller  bulb  sounds  are  used  to  determine  the  size  of  such  obstruc- 
tion. The  locations  of  all  constrictions  are  carefully  noted  as  to  their  depth 
and  size.  After  all  these  facts  have  been  determined  an  Otis  urethrotome  is 
introduced  into  the  urethra  and  the  indicator  turned  to  the  point  registering 
the  size  of  the  smallest  stricture,  the  point  of  the  urethrotome  being  inserted 
one-half  inch  beyond  the  location  of  this  stricture  as  determined  by  the  meas- 
urements. The  concealed  knife  is  directed  either  downwards  or  upwards,  so 
that  the  cut  will  be  precisely  in  the  median  line.  It  is  then  withdrawn  a 
distance  of  an  inch  or  a  little  more,  when  the  knife  is  forced  into  its  position 
of  concealment.  The  urethrotome  is  then  withdrawn  and  the  urethra  further 
measured  for  other  strictures ;  if  found  they  are  treated  in  the  manner  just 
described. 

After  repeated  examinations  determine  every  portion  of  the  urethra  to  be 
of  normal  size,  as  measured  by  the  bulb  sounds,  and  after  this  examination 


SUEGERY  OF  THE  GEXITO-UKIXAEY  TEACT  595 

has  indicated  the  urethra  to  be  uniform  in  size,  a  large  urethral  sound,  No. 
30  to  -±0  French,  according  to  the  size  of  the  patient,  is  introduced.  If 
the  bleeding  is  profuse  a  large  catheter  is  passed  and  the  cut  surface  is  held 
against  this  catheter  by  means  of  rubber  adhesive  straps  applied  circularly 
over  a  padding  of  cotton  at  least  one-half  inch  in  thickness.  In  this  manner 
hemorrhage  can  easily  be  controlled.  The  catheter  is  left  in  place  for  twenty- 
four  to  forty-eight  hours,  and  the  bladder  irrigated  through  it  with  one  of 
the  various  antiseptic  solutions  before  mentioned,  from  one  to  six  times  each 
day,  according  to  the  character  of  the  urine. 

After-care.  The  same  after-treatment  which  has  been  described  for  cystot- 
omy, so  far  as  the  administration  of  large  quantities  of  water  and  internal 
antiseptics  are  concerned,  should  be  followed.  After  the  fifth  day  steel 
urethral  sounds  or  hard  rubber  bougies  are  introduced,  at  first  once  every 
three  or  four  days,  then  every  second  day,  then  every  day,  and  when  the 
urethra  has  been  permanently  dilated  so  that  it  will  comfortably  take  the 
largest  desirable  sound  the  frequency  of  treatment  may  be  reduced  again; 
at  first  they  are  to  be  used  every  second,  then  every  third,  then  every  fourth 
day,  etc.,  until  presently  they  are  introduced  but  once  a  month.  This  should 
be  continued  for  many  months  until  the  surgeon  has  evidence  that  no  further 
contraction  will  take  place.  It  is  to  be  remembered  that  a  urethra  which  has  ' 
once  been  strictured  can  be  kept  open  with  much  less  difficulty  and  with  much 
greater  comfort  if  a  series  of  sounds  is  passed  once  a  month,  than  if  the  stric- 
ture is  permitted  to  reform  and  has  to  be  gradually  dilated. 

In  case  it  is  impossible  at  the  primary  examination  to  pass  a  sound  of  any 
size  through  the  stricture  the  patient  should  be  placed  in  bed  and  the  further 
treatment  which  has  been  mentioned  should  be  prolonged.  Patients  should 
also  be  given  hot  baths,  and  after  this  treatment  has  been  continued  for  some 
time  it  will  be  found  that  the  stricture  is  not  so  tight  as  it  was  at  the  beginning 
of  this  attention.  It  will  then  usually  be  possible  to  introduce  a  filiform  bougie. 
This  should  be  attached  to  the  end  of  a  conical  sound,  and  with  this  the  stric- 
ture slightly  distended.  After  this  has  been  accomplished  the  conical  sound 
is  replaced  with  the  urethrotome  and  the  stricture  cut  as  described  before. 
Entire  urethrotomy  is.  however,  not  safe  in  strictures  located  beyond  the  distal 
half  of  the  membranous  portion  of  the  urethra,  because  the  use  of  this  method 
is  likely  to  be  followed  by  severe  extravasation  of  blood  and  sometimes  by 
extravasation  of  urine;  the  latter  may  result  in  sloughing  of  a  great  amount 
of  tissue. 

EXTERNAL  URETHROTOMY 

Special  requirements  and  technique.  In  very  tight  strictures  of  the  mem- 
branous portion  of  the  urethra  it  is  probably  always  best  to  do  an  external 
instead  of  internal  urethrotomy.  If  the  stricture  is  tight,  however,  internal 
urethrotomy  should  always  precede  the  external,  because  with  a  filiform  bougie 
attached  to  the  conical  sound,  and  later  to  the  urethrotome,  as  has  just  been 
described,  it  is  practically  always  possible  to  split  the  stricture  smoothly  and 
with  the  infliction  of  as  little  unnecessary  traumatism  as  possible  to  the 
urethra ;  moreover,  after  internal  urethrotomy  has  been  performed  a  grooved 
steel  sound  can  be  introduced  into  the  urethra  and  then  external  urethrotomy 
done  without  great  difficulty. 

It  is  quite  the  opposite  if  an  external  urethrotomy  is  undertaken  in  a  tight 
stricture  instead  of  first  performing  an  internal  urethrotomy,  because  the  ex- 
ceedingly small  opening  in  the  strictured  portion  of  the  urethra  can  often  be 
found  only  with  the  greatest  amount  of  difficulty,  if  at  all,  and  in  the  search 
for  this  opening  a  great  amount  of  tissue  is  frequently  destroyed.     Had  the 


596  SURGERY  OF  THE  GENITO-URINARY  TRACT 

internal  urethrotomy  been  performed  in  the  same  case  before  the  external 
operation  was  attempted,  all  such  traumatism  would  be  avoided.  If,  however, 
it  is  impossible  to  introduce  a  filiform  bougie  through  the  stricture,  and  con- 
sequently impossible  to  do  an  internal  urethrotomy,  an  attempt  may  be  made 
at  finding  the  remaining  opening  through  an  external  incision.  Occasionally 
the  surgeon  may  be  more  fortunate  in  his  search  than  he  could  reasonably 
expect,  and  in  this  way  may  discover  the  remnant  of  the  original  canal.  If 
this  fails,  however,  after  a  reasonable  attempt,  it  is  best  to  perform  a  supra- 
pubic cystotomy  and  introduce  a  sound  into  the  urethra  by  the  way  of  the 
bladder,  and  carry  this  down  into  the  wound  of  the  urethra  to  the  point  of  the 
stricture,  and  then  cut  down  externally  upon  the  point  of  this  sound.  "With 
this  guide  it  will  then  be  possible  to  slit  open  the  stricture.  Preferably  a  fine 
probe  is  used,  which  is  introduced  from  the  upper  portion  of  the  stricture 
downward,  the  latter  being  at  the  end  of  the  sound  which  has  just  been  intro- 
duced from  the  bladder. 

After-treatment.  The  wound  is  then  left  open  and  dressed  with  ordinary 
antiseptic  dressings.  The  remnant  of  the  mucous  lining  of  the  urethra  will 
begin  to  proliferate  and  form  a  covering  of  mucous  membrane  over  the  adjoin- 
ing portion  of  the  wound.  Presently  it  will  show  a  tendency  to  close  in  upon 
itself  and  reproduce  the  original  canal.  In  the  meantime  care  should  be  taken 
not  to  permit  the  distal  end  of  the  urethra  becoming  again  contracted.  This 
may  be  prevented  by  the  introduction  of  steel  sounds  once  every  two  or  three 
days.  After  the  urethra  shows  a  tendency  to  close  a  catheter  should  be  intro- 
duced into  the  bladder  through  the  entire  length  of  the  urethra  and  the  wound 
permitted  to  heal  around  this  catheter.  The  same  precautions  for  the  dilution 
of  urine  which  have  been  described  after  suprapubic  cystotomy  should  be  em- 
ployed in  these  cases.  Occasionally  an  external  urethrotomy  is  indicated  by 
the  presence  in  the  urethra  of  a  fistula,  showing  the  existence  of  the  stricture 
to  the  distal  side  of  the  fistula.  The  operation  in  such  cases  is  the  same  as  that 
which  has  just  been  described, 

RUPTURE  OF  THE  URETHRA 

The  most  urgent  demand  for  an  external  urethrotomy  is  a  severe  trau- 
matism of  the  urethra.  This  is  usually  caused  by  falling  astride  some  hard 
substance,  such  as  a  beam  or  board  in  buildings  being  constructed,  or  fall- 
ing astride  a  wagon  wheel  by  teamsters,  or  falling  upon  the  pommel  of  the 
saddle  by  horsemen,  or  any  other  similar  accident.  The  patient  suffers 
severe  pain  in  the  region  of  the  perineum ;  there  is  usually  a  flow  of  a  vari- 
able amount  of  blood  from  the  urethra ;  there  is  an  obstruction  to  the  flow 
of  urine,  and  upon  introducing  a  catheter  into  the  urethra  it  brings  blood, 
but  no  urine.  If  the  injury  is  recent  these  may  be  all  the  symptoms  deter- 
mined. If  it  has  existed  for  a  longer  time  there  is  severe  ecchymosis,  there 
may  be  marked  edema,  and  there  frequently  is  an  area  of  necrosis,  which 
varies  with  the  severity  of  the  injury  and  length  of  time  that  has  elapsed 
since  its  occurrence. 

If  the  catheter  passes  the  obstruction  and  enters  the  bladder,  this  will 
be  indicated  by  a  flow  of  urine.  In  such  event,  it  is  wise  to  irrigate  the 
bladder  with  some  antiseptic  substance  and  to  leave  the  catheter  in  place, 
for  fear  of  not  being  able  to  reintroduce  it,  for  the  purpose  of  preventing 
extravasation  of  urine  by  the  perfect  draining  of  the  bladder,  and  also  for 
the  purpose  of  acting  as  a  splint  in  directing  the  process  of  healing  in  the 
ruptured  urethra.  If  the  surgeon  is  not  fortunate  enough  to  introduce  the 
catheter  into  the  bladder  without  the  use  of  force,  he  should  abandon  the 


SURGERY  OF  THE  GENITO-URINARY  TRACT  597 

attempt  without  having  increased  the  existing  traumatism,  the  only  rational 
means  then  of  treating  these  cases  being  with  an  external  incision. 

Technique.  The  patient  is  placed  in  the  lithotomy  position;  the  skin  pre- 
pared for  operation ;  a  longitudinal  wound  made  upon  the  end  of  the  urethral 
sound  which  has  been  introduced  to  the  point  of  obstruction.  This  sound 
will  indicate  the  location  of  the  distal  end  of  the  urethra.  If  it  is  difficult  to 
locate  the  proximal  end  of  the  urethra  this  can  usually  be  effected  by  making 
gradual  pressure  upon  the  bladder,  thus  forcing  out  some  of  the  urine,  which 
will  indicate  the  proximal  end  of  the  canal.  The  incision  is  then  prolonged 
until  it  passes  the  proximal  end  of  the  urethra  for  about  an  inch.  The  two 
extremities  of  the  urethra  are  then  united  by  means  of  fine  catgut  sutures 
for  about  two-thirds  of  their  circumference,  the  most  superficial  third  being 
left  for  drainage.  A  catheter  is  then  introduced  through  the  entire  urethra 
into  the  bladder,  and  the  remaining  portion  of  the  wound  permitted  to  heal 
by  granulation. 

It  has  been  our  experience  that  a  complete  union  of  the  urethra  in  these 
cases  can  be  accomplished  much  more  rapidly  and  perfectly  if  the  entire 
circumference  of  the  urethra  is  not  sutured  at  once  at  the  time  of  the  first 
operation. 

After-treatment.  The  after-treatment  is  the  same  as  before  mentioned. 
The  retention  catheter  is  left  in  place  until  the  wound  in  the  urethra  has 
apparently  completely  healed.  If  the  patient  does  not  come  under  the  sur- 
geon's care  until  a  considerable  portion  of  the  urethra  has  become  necrotic, 
it  may  be  necessary  to  excise  this  and  bring  together  portions  of  the  urethra 
a  considerable  distance  from  each  other.  This,  however,  can  be  done  with 
safety  and  with  comfort  to  the  patient. 

RESECTION  OF  THE  STRICTURED  URETHRA 

The  same  conditions  may  be  established  if  a  portion  of  the  urethra  has 
been  entirely  destroyed  by  inflammatory  processes,  leaving  a  cicatricial  stric- 
ture, in  which  a  recovery  of  the  lumen  of  the  urethra  is  impossible.  In  such 
cases  the  cicatricial  stricture  is  entirely  excised  and  the  urethra  above  and 
below  united  by  means  of  fine  catgut  sutures,  the  most  superficial  third  of 
the  circumference  of  the  urethra  being  again  left  open.  A  retention  catheter 
is  introduced  and  the  wound  dressed  in  the  usual  way. 

Prognosis.  The  prognosis  in  all  of  these  cases  treated  for  a  long  period 
of  time  after  they  have  apparently  completely  recovered  is  relatively  very 
good,  provided  no  further  gonorrheal  urethritis  occurs.  It  is,  however,  to  be 
remembered  that  these  patients  should  return  to  the  surgeon  from  time  to 
time,  so  that  he  may  determine  the  tendency  to  recurrence  of  stricture  at  a 
period  when  the  condition  can  be  most  easily  relieved,  and  if  any  such  tend- 
ency exists,  it  should  be  overcome  by  the  careful  use  of  sounds  before  it  has 
reached  an  advanced  stage. 

VASECTOMY 

The  excision  of  the  vas  deferens  may  become  necessary  on  account  of 
tuberculosis  of  this  organ,  which  is  not  uncommon,  or  on  account  of  a  malig- 
nant growth  (sarcoma  extending  to  the  vas  deferens  from  the  testicle  being 
the  most  common  cause),  or  the  operation  may  be  performed  with  a  hope 
of  causing  a  reduction  in  the  size  of  an  hypertrophied  prostate  gland.  It  is 
likely  that  this  operation  will  be  employed  for  the  purpose  of  securing  ster- 
ility in  patients,  either  physically,  mentally  or  morally  impaired  to  such  an 
extent  as  to  make  their  progeny  dangerous  to  the  community  at  large. 


598  SURGERY  OF  THE  GENI TO-URINARY  TRACT 

Technique.  The  extent  of  the  procedure  will  depend  upon  the  condition 
for  which  it  is  to  be  performed.  If  a  considerable  portion  of  the  vas  deferens 
is  diseased  the  incision  should  extend  from  the  external  abdominal  ring  down 
to  the  lower  portion  of  the  scrotum.  The  tissues  of  the  cord  being  exposed, 
the  vas  deferens  will  be  recognized  as  a  hard,  round  cord.  This,  in  case  of 
malignancy,  should  be  removed,  together  with  all  the  tissues  of  the  cord  and 
the  testicle.  In  case  it  is  tubercular  and  the  disease  has  not  penetrated  the 
organ  and  infected  the  surrounding  tissues,  it  is  separated  from  the  adja- 
cent parts  to  a  point  two  centimeters  or  more  beyond  the  affected  portion. 
It  is  then  ligated  with  catgut  at  each  end  and  excised. 

If  the  entire  vas  deferens  is  tubercular  it  should  be  carefully  dissected 
as  far  up  in  the  inguinal  canal  as  is  possible  without  fear  of  breaking  it  off. 
A  syringe  with  a  blunt-pointed  needle  is  then  filled  with  ninety-five  per  cent, 
carbolic  acid.  The  needle  is  introduced  into  the  vas  deferens  and  the  car- 
bolic acid  injected  very  slowly  into  its  lumen.  After  the  acid  has  been  in 
contact  for  five  minutes  the  syringe  is  filled  repeatedly  with  strong  alco- 
hol, which  is  also  injected  through  the  lumen  of  the  vas  deferens  in  order 
to  prevent  the  carbolic  acid  from  causing  too  much  destruction. 

Should  the  operation  be  intended  only  for  the  interruption  of  the  con- 
tinuity of  the  canal,  a  small  incision  two  centimeters  in  length  is  made  opposite 
the  external  abdominal  ring,  the  tissues  of  the  cord  are  brought  into  the 
incision,  the  vas  deferens  is  separated  from  the  other  structures  of  the  cord, 
two  catgut  ligatures  are  applied  a  centimeter  apart,  and  the  intervening 
portion  excised.  The  tissues  of  the  cord  are  then  replaced  and  the  wound  in 
the  skin  closed  with  one  stitch. 

Regarding  the  eft'ect  of  this  operation  for  the  relief  of  hypertrophy  of 
the  prostate  gland,  we  should  say  that  there  are  undoubtedly  certain  patients 
Avho  are  permanently  benefited  by  this  form  of  treatment.  It  is,  however, 
impossible  to  determine  beforehand  which  patients  will  be  so  improved,  and 
consequently  it  is  impossible  to  make  a  reliable  prognosis.  The  operation 
in  itself  is  simple ;  it  can  easily  be  performed  under  cocaine  anesthesia ;  it  is 
not  accompanied  by  pain;  and  results  in  no  deformity.  All  of  these  reasons 
make  it  one  which  should  not  be  condemned,  although  the  relative  number 
of  permanent  recoveries  is  not  sufficient  to  warrant  its  general  adoption. 

PROSTATECTOMY 

This  operation  has  grown  greatly  in  favor  during  the  past  few  years, 
principally  because  attention  has  been  paid  to  its  careful  technical  develop- 
ment. It  is  performed  entirely  for  the  removal  of  hypertrophied  prostate 
glands.  "We  will  only  describe  the  perineal  method,  because  the  suprapubic 
method  virtually  corresponds  to  the  operation  for  suprapubic  cystotomy,  to 
which  is  added  the  enucleation  of  one  or  more  lobes  of  the  enlarged  prostate 
gland  projecting  into  the  bladder.  For  all  eases  of  prostatic  enlargement 
in  which  there  is  not  a  distinct  projecting  lobe  into  the  bladder,  we  would 
perform  the  perineal  operation. 

General  considerations.  In  the  consideration  of  this  operation  it  must  be 
remembered  that  patients  upon  whom  it  is  performed  are  usually  advanced 
in  years,  because  hypertrophy  of  the  prostate  gland  occurs  most  frequently 
at  such  time.  There  has  been  an  obstruction  to  the  passage  of  urine,  which 
has  usually  resulted  in  the  accumulation  of  residual  urine  in  the  bladder,  pre- 
disposing to  infection  and  consequent  cystitis.  Many  of  these  patients  have 
infected  their  bladders  mechanically  by  the  use  of  septic  catheters ;  in  many 
these  conditions  have  resulted  in  the  formation  of  stone ;  in  many,  again, 
the  infection  has  advanced  by  one  or  both  ureters  into  the  pelvis  of  the  kid- 


SURGEEY  OF  THE  GENITO-URINARY  TRACT 


599 


ney,  giving  rise  to  a  pyelitis ;  and  still  again  many  are  found  suffering  from 
a  chronic  nephritis,  which  is  not  uncommon  in  patients  advanced  in  years, 
though  there  may  be  no  direct  mechanical  cause  for  its  occurrence.  All 
these  facts  would  indicate  that  this  operation,  as  a  rule,  is  done  on  a  class 
of  patients  who  are  not  well  fitted  to  endure  any  serious  surgical  undertaking, 
which  must  of  course  be  borne  in  mind  when  this  operation  is  suggested.    The 


Pkostatectoaiy. 

A  liorseshoe  shaped  incision  is  shown  -with  the  two  branches  opposite  the  tuber  ischii.  The 
flap  is  drawn  backward  by  a  vaginal  speculum  (d)  ;  the  wound  is  held  open  laterally  by  the 
retractors  (ee)  ;  the  urethra  is  seen  deep  in  the  wound  anteriorly  at  (c)  ;  the  prostate  glajid 
(b)  is  diawn  downward  by  means  of  the  cat's-paw  retractor  (a). 


facts  which  are  in  favor  of  this  operation  in  those  whose  general  condition  is 
not  good  are : 

1.  That  the  patient  will  be  relieved  of  pain. 

2.  The  drainage  of  the  bladder  which  follows  the  operation  relieves  the 
urinary  obstruction  and  at  the  same  time  prevents  further  septic  absorption 
from  residual  urine. 

3.  The  bladder  is  accessible  to  irrigation  after  this  operation,  so  that 
any  septic  material  which  may  be  secreted  from  its  walls  can  be  frequently 
washed  away. 


600  SURGERY  OF  THE  GENITO-URINARY  TRACT 

4.  The  patient  is  not  exposed  to  the  likelihood  of  infection  in  the  future, 
which  is  almost  inevitable  if  he  is  compelled  to  resort  to  the  daily  use  of  a 
catheter  for  the  purpose  of  evacuating  the  bladder. 

Preliminary  treatment  for  prostatectomy.  In  eases  in  which  there  has 
been  long-continued  obstruction  to  the  passage  of  the  urine  as  a  result  of  the 
enlarged  prostate  gland  it  is  important  that  preliminary  treatment  should  be 
instituted.  This  treatment  should  consist  of  the  administration  of  antiseptics 
such  as  urotropin  in  doses  of  from  five  to  fifteen  grains  in  half  a  pint  of  hot 
water,  preferably  distilled  water,  once  every  six  to  eight  hours  for  a  number 
of  days,  or  the  use  of  five  grains  of  quinine  with  half  a  pint  of  hot  water 
every  six  hours  for  a  number  of  days.  The  bladder  should  be  irrigated  with 
a  solution  of  1  to  2,000  permanganate  of  potash  in  water.  This  should  be 
entirely  withdrawn,  and  then  a  quantity  of  saturated  solution  of  boric  acid 
in  water,  equal  to  one-half  of  the  residual  urine,  should  be  left  in  the  bladder. 
The  bladder  should  be  emptied  and  irrigated  from  two  to  four  times  a  day 
for  several  days  previous  to  the  operation.  In  severe  cases  in  which  it  is 
difficult  to  catheterize,  it  is  well  to  permit  the  bladder  to  become  thoroughly 
distended,  then  to  insert  a  large  trocar  just  above  the  pubis,  but  stop  the 
outer  opening  of  this  trocar  with  the  finger  and  to  insert  through  the  canula 
of  the  trocar  a  retention  catheter  and  then  to  withdraw  the  canula  and  leave 
the  catheter  in  place.  The  bladder  should  be  irrigated  two  to  four  times 
each  day  through  this  retention  catheter  as  described  above,  the  same  amount 
of  boric  acid  solution  being  left  in  place  each  time.  In  place  of  the  trocar 
and  retention  catheter,  the  very  ingenious  apparatus  devised  by  Professor 
Rodman  may  be  used. 

Of  late  we  have  usually"  made  a  suprapubic  cystotomy  under  local  anethesia 
with  novocaine,  making  an  opening  in  the  bladder  only  just  large  enough  to 
insert  the  smaller  one  of  the  double  tube  previously  illustrated,  and  fastening 
this  in  place  by  suturing  the  outer  tube  by  means  of  a  few  catgut  sutures. 
By  using  this  double  tube,  there  is  no  danger  of  the  inner  tube  becoming 
plugged  because  of  a  protruding  suture  or  pin  into  its  lumen.  Moreover,  the 
outer  tube  stiffens  the  inner  one  so  that  it  is  less  likely  to  be  shut  off  by  kink. 
By  attaching  a  drainage  tube  to  the  distal  end  of  this  rubber  tube  and  passing 
it  over  the  edge  of  the  bed  into  a  bottle,  the  patient  can  be  kept  perfectly  dry. 

If  the  bladder  contains  much  mucus,  it  is  advantageous  to  irrigate  with 
boric  acid  solution  several  times  daily.  If  the  patient  is  given  large  quantities 
of  distilled  water  to  drink,  as  much  as  half  a  pint  every  half  hour,  or  if  he  is 
given  considerable  quantities  of  watermelon  to  eat,  the  urine  usually  becomes 
perfectly  clear  and  the  bladder  walls  improve  with  great  rapidity,  so  that 
after  one  to  two  weeks  it  is  safe  to  perform  the  prostatectomy. 

It  remains  now  to  reduce  to  the  minimum  the  amount  of  traumatism 
required  for  the  removal  of  the  enlarged  prostate  gland.  We  believe  that 
the  operation  herewith  described  fills  this  requirement. 

It  is  important  that  patients  about  to  undergo  this  operation  should  be 
carefully  prepared  in  the  manner  described  in  connection  with  suprapubic 
cystotomy.  These  cases  are  almost  all  chronic  in  character  when  they  reach 
the  hands  of  the  surgeon ;  consequently  a  few  weeks  spent  in  securing  as 
aseptic  a  condition  of  their  bladders  as  possible  is  not  of  much  importance 
to  them.  It  is  not  so  much  of  a  hardship  to  a  man  to  postpone  his  relief 
for  a  few  weeks,  after  he  has  suffered  for  a  long  time,  as  it  would  be  if 
his  suffering  were  acute,  and  we  believe  that  success  depends  to  a  very  large 
extent  upon  the  careful  preparatory  treatment. 

Technique.  Before  beginning  the  operation,  the  bladder  is  carefully  irri- 
gated with  one  of  the  mild  antiseptic  fluids  mentioned  before  in  connection 
with  bladder  surgery,  until  the  fluid  returns  perfectly  clear.     The  bladder  is 


SURGERY  OF  THE  GEXITO-URIXARY  TRACT  601 

then  completely  emptied  by  p»lacing  a  soft  rubber  catheter  so  that  it  will  act  as  a 
siphon,  and  by  making  pressure  upon  the  bladder  above  the  pubis.  Five  hun- 
dred cc.  of  saturated  boric  acid  solution  is  then  introduced  into  the  bladder  and 
the  soft  rubber  catheter  removed.  So  far  the  preparation  is  the  same,  without 
regard  to  the  method  of  operation  to  be  chosen.  During  the  past  few  years 
we  have  practised  the  following  technique,  although  our  results  have  not 
been  better  than  they  were  when  we  followed  the  method  to  be  described 
later.  It  has  seemed  to  us,  however,  as  though  by  following  this  method  we 
reduced  the  traumatism  to  a  minimum,  and  that  consequently,  our  patients 
showed  almost  no  surgical  shock  following  the  operation. 

A  grooved,  steel  sound  is  carefully  passed  into  the  urethra  until  it  has 
fully  entered  the  membranous  portion.  It  is  then  held  by  an  assistant  so  that 
the  point  of  the  sound  presses  against  the  perineum.  An  incision  is  then  made 
■1  cm.  in  length  from  a  point  half  way  between  the  scrotum  and  the  anus, 
downwards  and  to  the  patient's  left  through  the  wall  of  the  urethra.  An 
old-fashioned  lithotomy  knife  is  then  passed  through  this  incision  so  that  the 
button  at  the  end  of  the  knife  rests  in  the  groove  of  the  steel  sound,  and  the 
two  of  them  passed  into  the  bladder  simultaneously,  care  being  taken  to  have 
the  steel  sound  hug  the  pubic  bone  closely.  In  this  manner  the  posterior  wall 
of  the  prostatic  urethra  and  the  membranous  urethra  are  split  throughout 
their  course,  the  knife  and  the  sound  being  carried  quite  into  the  bladder. 
The  index  finger  is  then  introduced  into  the  bladder  through  this  opening  and 
the  point  of  the  finger  carried  down  into  the  prostate  gland  laterally,  precisely 
as  though  a  supra-pubic  prostatectomy  were  being  made.  The  gland  is  sepa- 
rated from  its  capsule  throughout.  If  any  points  are  encountered  in  which 
there  are  shreds  which  cannot  be  separated,  these  are  cut  with  scissors,  care 
being  taken  to  cause  as  little  traumatism  to  the  prostatic  urethra  as  possible. 

If  there  is  any  hemorrhage,  hemostatic  forceps  are  applied  and  the  capsule 
and  wound  are  tamponed  with  strips  of  gauze,  care  being  taken  to  examine  the 
neck  of  the  gall-bladder  for  nodules  of  prostatic  tissue  which  may  remain, 
which  will  have  to  be  removed  separately.  Care  also  should  be  taken  to  pre- 
vent the  edges  of  the  capsule  from  folding  into  the  bladder.  In  this  way 
hemorrhage  can  easily  be  prevented. 

The  tampon  is  removed  on  the  second  day,  and  from  the  fifth  day  on  the 
patient  receives  a  daily  warm  tub  bath.  Usually  the  urine  passes  normally 
after  ten  days,  sometimes  a  little  earlier  and  sometimes  later.  The  operation 
is  amazingly  simple,  representing,  in  fact,  a  supra-pubic  prostatectomy  made 
through  a  perineal  wound  and  containing  the  advantages  of  supra-pubic  and 
perineal  operations.  Following  this  operation  it  is  rarely  necessary  to  make 
use  of  irrigation. 

For  any  one  who  prefers  to  operate  in  full  view  of  the  field,  the  operation 
which  has  been  perfected  by  Dr.  Hugh  Young,  which  we  have  practised  in  a 
great  number  of  cases,  gives  most  excellent  results.  The  preparation  is  the 
same  as  for  the  operation  just  described. 

In  case  a  preliminary  supra-pubic  drainage  has  been  applied,  the  bladder  is, 
of  course,  not  filled  with  fluid  before  beginning  either  this  or  the  previous 
operation.  A  steel  sound  Ls  introduced  to  the  prostatic  portion,  but  not 
through  it,  to  act  as  a  guide  in  locating  the  urethra.  A  crescent-shaped  in- 
cision is  then  made  from  a  point  opposite  the  tuberosity  of  the  ischium  on 
one  side  to  that  on  the  other,  the  convex  portion  extending  across  the  perineum, 
as  indicated  in  the  plate.  With  a  finger  in  the  rectum  and  the  steel  sound  in 
the  urethra  one  can  readily  and  safely  make  the  dissection  forward  until  the 
entire  lower  surface  of  the  prostate  gland  is  exposed,  as  shown.  A  few 
insignificant  vessels  will  be  encountered,  and  from  each  side  there  will  be  one 
or  more  divisions  of  the  internal  pudic  artery,  which  will  bleed  freely,  but  it 


602  SURGERY  OF  THE  GENITO-URINARY  TRACT 

can  be  grasped,  either  before  or  after  division,  with  hemostatic  forceps  and 
ligated  at  once  in  order  to  leave  the  space  entirely  free.  All  of  the  smaller 
vessels  may  be  grasped  and  also  ligated,  the  important  point  in  this  portion 
of  the  operation  being  the  complete,  careful  exposure  of  the  prostate  gland. 
A  sharp-toothed  cat's-paw  retractor  is  then  caught  in  one  lobe  of  the  gland 
and  the  latter  drawn  downward.  With  a  sharp  scalpel  the  capsule  of  the 
other  lobe  is  then  incised  deeply,  care  being  taken  not  to  approach  the 
middle  portion  of  the  gland.  A  second  retractor  of  the  same  kind  is  then 
inserted  into  the  lobe  which  has  just  been  incised,  and  the  gland  kept  drawn 
down  while  a  second  deep  incision  is  made  through  the  capsule  of  the  second 
lobe.  While  the  gland  is  still  held  downwards  by  means  of  the  cat's-paw 
retractor,  a  finger  is  introduced  into  the  incision  which  has  just  been  made 
and  one  lobe  of  the  gland  freed  from  its  capsvile,  regard  being  taken  not 
to  approach  the  median  portion.  The  retractor  is  then  again  changed  to 
the  other  lobe,  and  the  second  lobe  is  enucleated  with  the  finger,  care  being 
again  taken  not  to  approach  the  middle  portion  until  the  lobe  has  been  entirely 
freed.  In  this  manner  a  considerable  amount  of  annoying  hemorrhage  is 
avoided,  which  comes  from  the  submucous  veins  at  the  neck  of  the  bladder. 
In  case  the  middle  lobe  is  approached  at  first,  these  veins  are  likely  to  cause 
a  sufificient  amount  of  bleeding  to  cloud  the  field  of  operation. 

One  finger  is  now  introduced  behind  each  lobe,  and  by  bringing  the  two 
fingers  together  posteriorly,  the  entire  gland  can  usually  be  rolled  out  for- 
ward. The  anterior  attachment  is  then  cut  away  with  scissors,  in  order  not 
to  disturb  the  anterior  portion  of  the  prostatic  urethra  unnecessarily.  A 
gauze  pad  .is  inserted  at  once  to  make  a  slight  amount  of  pressure,  which  will 
cause  the  bleeding  to  subside  readily. 

A  finger  is  then  introduced  into  the  bladder  in  order  to  determine  the 
presence  of  one  or  more  stones.  Occasionally,  after  a  thorough  examination 
of  the  bladder  with  a  steel  sound  has  failed  to  determine  stones,  the  digital 
examination  after  the  removal  of  the  prostate  gland  will  still  demonstrate 
their  presence.  If  stones  are  found  the  surgeon  should  determine  whether 
the  opening  in  the  bladder  is  sufficiently  large  to  permit  their  extraction.  If 
not  then  an  incision  is  made  posteriorly  until  the  desired  size  has  been  obtained. 
The  stones  are  then  removed  in  the  ordinary  manner.  In  ordinary  cases  all 
that  remains  to  be  done  is  the  introduction  of  a  rubber  tube,  with  numerous 
small  perforations  near  the  end,  to  the  fundus  of  the  bladder.  This  should 
be  stitched  into  the  angle  of  the  wound.  A  piece  of  iodoform  gauze  may  then 
be  tamponed  against  the  remaining  portion  of  the  capsule  of  the  prostate 
gland  and  permitted  to  protrude  from  the  wound  of  the  perineum  near  the 
point  at  which  the  drainage  tube  issues.  A  few  stitches  are  then  applied  to 
replace  the  flap. 

We  believe  that  it  is  best  not  to  suture  the  flap  too  tightly,  because  there 
will  be  considerable  oozing,  and  if  there  is  a  sufficient  amount  of  space  for 
drainage  to  take  place  the  patient  will  be  saved  the  possibility  of  the  accu- 
mulation of  wound  secretion.  If  the  bladder  has  been  severely  infected  we 
believe  it  is  better  to  introduce  two  drainage  tubes  a  little  smaller  in  size  to 
the  fundus  of  the  bladder  so  that  irrigation  may  be  accomplished  by  injecting 
the  irrigating  fluid  through  one  tube  and  permitting  it  to  escape  through  the 
other  after  the  operation.  In  case  there  should  be  considerable  hemorrhage 
from  the  capsule — which,  however,  is  not  common — this  may  be  controlled  by 
the  application  of  a  few  hemostatic  forceps,  which  are  permitted  to  protrude 
through  the  wound,  and  which  may  be  removed  after  twelve  or  twenty-four 
hours  with  safety.  If  there  is  much  oozing  the  space  may  be  tamponed  with 
sufficient  iodoform  gauze  to  overcome  it,  but  it  does  not  frequently  happen 
that  the  tissues  require  this  form  of  tamponing. 


SURGERY  OF  THE  GENITO-URINARY  TRACT  603 

After-treatment.  The  bladder  should  be  irrigated  with  one  of  the  various 
mild  antiseptic  fluids  from  one  to  six  times  a  day,  according  to  the  condition 
of  the  viscus  wall.  The  iodoform  gauze  is  withdrawn  after  the  second  or 
third  day,  and  from  the  fifth  to  the  tenth  day  the  rubber  drainage  tube_  is 
removed.  In  many  cases  the  patient  has  no  difficulty  after  this  time  with 
evacuating  the  bladder  normally,  but  if  the  flow  of  urine  is  not  normal  it  is 
wise  to  introduce  a  soft  rubber  catheter  through  the  urethra  into  the  bladder 
for  a  few  days.  It  is  well  to  remove  it  every  second  or  third  day  to  see 
whether  the  normal  conditions  have  been  established,  and  if  they  have  not, 
the  catheter  may  be  replaced.  During  this  period  it  is  well  to  give  some 
mild  antiseptic  internally  and  to  give  the  patient  large  quantities  of  pure 
water,  in  order  to  dilute  the  urine.  It  is  well  to  encourage  him  to  sit  up  the 
second  or  third  day  after  the  operation,  and  to  get  out  of  bed  as  soon  as 
possible,  because  men  at  this  age  do  not  bear  confinement  very  well. 

Prognosis.  Bearing  in  mind  the  condition  of  these  patients,  aside  from 
that  of  the  prostate  gland,  they  withstand  this  operation  remarkably  well, 
and  the  difference  in  the  comfort  of  the  patient  and  the  improvement  in  his 
general  condition  is  very  marked.  In  many  cases  the  free  drainage  seems  to 
improve  the  function  of  the  kidneys  decidedly,  so  that  after  a  few  months  a 
marked  albuminuria  may  almost  entirely  disappear.  The  fact  that  a  constant 
source  of  septic  infection  has  been  removed  is  of  very  great  importance  to 
the  general  health  of  the  patient.  We  believe  this  operation  adds  many  years 
to  the  lives  of  these  sufferers. 

Complications.  Occasionally  it  will  be  found  that  the  existing  adhesions 
prevent  the  enucleation  of  any  considerable  portion  of  the  prostate  gland, 
and  that  in  order  to  remove  it  in  the  manner  just  described  it  will  be  neces- 
sary to  produce  too  severe  a  traumatism ;  consequently  if  it  is  found  impossible 
to  enucleate  the  lobes  of  the  prostate  as  described,  the  following  method 
should  be  substituted : 

The  operation  is  performed  as  described  above  to  the  point  of  enucleation. 
This  is  attempted,  but  if  it  proves  unsuccessful,  the  sharp-toothed  cat's-paw 
retractor  is  applied  to  one  lobe,  and  the  substance  of  the  gland  removed 
piecemeal  with  cutting  forceps.  The  extent  to  which  it  has  to  be  removed 
can  easily  be  determined  by  inserting  the  finger  into  the  field  of  operation 
from  time  to  time.  The  operation  is  more  tedious  than  enucleation,  but  much 
safer  than  in  cases  in  which  enucleation  cannot  be  readily  accomplished. 
The  drainage  of  the  bladder  and  the  after-treatment  are  the  same  as  described 
before. 

PROSTATOTOMY 

This  operation  is  performed  for  the  relief  of  abscess  of  the  prostate  gland. 
In  young  individuals  with  an  infection  of  the  gland,  due  to  specific  urethritis, 
it  is  often  found  that  the  gland  is  filled  with  multiple  abscesses,  which  will 
keep  the  patient  in  a  slightly  septic  condition  for  a  long  time.  This  infection 
may  progress  to  form  larger  abscesses,  but  these  usually  have  for  their  excit- 
ing cause  the  introduction  of  steel  sounds  or  bougies.  The  abscess  may 
increase  in  size  to  such  an  extent  as  to  produce  a  swelling  in  the  region  of  the 
perineum,  or  it  may  produce  a  fluctuating  tumor  in  the  rectum.  This  is  accom- 
panied by  severe  pains  and  symptoms  of  acute  suppuration.  A  large  abscess 
that  causes  swelling  in  the  region  of  the  perineum  should  be  opened  through 
a  perineal  section,  being  careful  not  to  injure  either  the  rectum  or  the  urethra. 
It  is  well  to  make  the  incision  quite  into  the  prostate  gland,  to  curette  away 
the  infectious  material,  and  tampon  the  cavity  with  iodoform  gauze.  If  the 
fluctuation  can  be  discovered  by  digital  examination  through  the  rectum,  th,e 


604  SURGERY  OF  THE  GENITO-URINARY  TRACT 

incision  just  described  may  be  used,  or  the  swelling  in  the  rectum  may  be 
exposed  by  the  use  of  retractors  and  the  abscess  opened  into  the  rectum  by 
the  use  of  the  actual  cautery.  In  this  event,  the  opening  should  be  made 
large  enough  to  insure  permanent  drainage.  The  opening  will  increase  in  size 
if  it  has  been  made  by  the  cautery,  because  the  eschar  which  is  formed 
throughout  the  circumference  of  the  opening  will  fall  off  as  healing  pro- 
gresses, and  thus  increase  this  aperture. 

Much  has  been  said  against  the  opening  of  prostatic  abscesses  into  the 
rectum  for  fear  of  infection.  If  the  wound  has  been  made  as  just  described, 
and  if  the  patient  has  received  proper  preliminary  treatment,  consisting  in 
the  administration  of  two  ounces  of  castor  oil  for  two  successive  days  previous 
to  the  operation,  with  thorough  repeated  flushings  of  the  bowel  before  the 
operation,  and  if  the  operation  is  followed  by  proper  after-treatment,  consist- 
ing in  the  administration  of  a  saline  laxative  daily  and  thorough  flushing 
after  the  evacuation  of  the  bowels,  then,  according  to  our  experience,  the 
results  will  be  perfectly  satisfactory.  It  is  quite  different  if  the  abscess  is 
simply  incised,  especially  if  the  preliminary  and  after-treatment  are  not  car- 
ried out  with  care. 

In  the  presence  of  multiple  small  abscesses  of  the  prostate  gland,  resulting 
from  repeated  infections  from  gonorrheal  urethritis,  the  gland  is  exposed  as 
in  the  operation  described  for  perineal  prostatectomy.  Then  it  is  drawn  down 
and  a  deep  incision  made  transversely  across  each  lobe  of  the  prostate,  and 
this  is  carefully  tamponed  with  iodoform  gauze.  A  small  rubber  drainage 
tube  is  introduced  to  each  lobe  of  the  gland,  but  not  into  it,  and  the  wound 
closed  with  sutures,  with  the  exception  of  the  two  lower  angles  through  which 
the  rubber  drainage  tube  and  the  iodoform  gauze  issue. 

Prognosis.  This  operation  may  result  in  the  complete  relief  of  the  patient, 
especially  if  he  has  not  the  misfortune  of  acquiring  a  further  gonorrheal 
urethritis.  In  many  cases,  however,  the  recovery  is  not  permanent,  and  it 
will  be  necessary  to  perform  a  prostatectomy  in  order  to  give  permanent 
relief. 

EPIDIDYMECTOMY 

In  a  majority  of  cases  of  tuberculosis  of  the  testicles  they  are  involved 
secondarily,  the  primary  tuberculosis  being  in  the  epididymis,  and  in  many 
cases  in  which  the  testicle  is  supposed  to  be  tuberculous  a  careful  examina- 
tion will  reveal  the  fact  that  the  disease  is  still  confined  to  the  epididymis. 
If  this  is  the  case,  it  is,  of  course,  not  necessary  to  disturb  the  testicle  during 
the  operation,  which  should  simply  consist  in  making  a  wedge-shaped  excision 
of  the  epididj'mis,  together  with  the  vas  deferens,  which  is  usually  involved, 
and  to  close  the  defect  with  fine  catgut  sutures.  Even  if  there  is  a  moderate 
infection  of  the  testicle,  a  conical  excision  of  the  diseased  area  may  be  made 
when  the  epididymis  is  removed,  and  the  defect  closed  with  buried  catgut 
sutures.  It  is  only  in  case  of  multiple  tubercular  foci  in  the  testicle,  in  which 
it  seems  impossible  to  preserve  any  portion  of  the  organ,  in  which  the  multiple 
puncture  with  the  actual  cautery  is  indicated,  because  with  this  method  it  is 
possible  to  preserve  a  remnant  of  the  organ,  even  if  apparently  the  entire 
gland  has  been  destroyed  by  the  tuberculosis. 

It  is  plain  that  a  wound  made  in  this  manner  cannot  heal  so  quickly  as  a 
clean  cut  one,  but  the  patient  is  very  willing  to  undergo  the  necessary  annoy- 
ance in  order  to  secure  the  resulting  benefit. 

The  cicatricial  tissue  which  develops  as  a  result  of  the  cauterization  seems 
to  do  much  to  prevent  the  further  destruction  of  the  organ  by  tuberculosis. 

If  the  vas  deferens  is  involved  in  the  tuberculous  process  jt  should  be 


SURGERY  OF  THE  GENITO-URINARY  TRACT  605 

excised.  It  is  not  difficult  to  follow  this  structure  to  a  point  near  the  bladder 
by  slowly  drawing  it  up  into  the  wound  and  freeing  it  from  the  surrounding 
tissues  by  pressure  with  a  moist  gauze  pad.  The  external  incision  may  be 
carried  to  a  point  just  outside  the  external  abdominal  ring.  The  diseased 
portion  of  the  vas  deferens  is  somewhat  uneven  and  nodular.  It  is  well  to 
remove  the  structure  to  a  point  some  distance  beyond  the  portion  that  is 
diseased.  In  order  not  to  have  the  vas  severed  too  near  the  diseased  portion 
it  is  well  to  make  the  dissection  very  slowly,  and  then  place  a  pair  of  hemo- 
static forceps  at  the  point  where  it  is  desired  to  sever  the  structure,  to  apply 
a  ligature  at  this  point  and  then  cut  just  proximally  to  the  ligature.  If  the 
seminal  vesicles  are  left  in  place,  and  also  the  testicles,  the  patient's  sexual 
life  will  not  be  disturbed  in  the  least  by  this  operation,  even  if  both  vasa 
deferencia  are  removed.  This  fact  is  important  in  connection  with  this  opera- 
tion when  performed  for  the  purpose  of  securing  sterility  of  the  male  for 
sociological  reasons. 

It  has  been  suggested  to  perform  vasectomy  for  the  sterilization  of  habitual 
criminals,  epileptics,  idiots  and  other  degenerates  for  the  protection  of  the 
community. 

In  this  it  is  not  necessary  to  make  so  extensive  an  operation.  The  skin 
over  the  vas  deferens  may  be  anesthetized  by  the  injection  of  a  one  per  cent, 
solution  of  cocaine,  injected  also  about  the  vas,  which  is  brought  out  through 
an  incision  two  cm.  long ;  it  is  ligated  twice  at  a  distance  of  one  cm.  apart  and 
then  severed.  The  wound  is  closed  with  one  or  two  fine  catgut  sutures  and 
the  operation  repeated  on  the  opposite  side. 

The  operation  is  justified  by  the  fact  that  the  community  gains  enormously 
while  the  individual  loses  nothing.  He  is  not  exposed  to  any  risk,  suffers  no 
pain  and  is  not  inconvenienced  in  any  other  way  except  that  parentage  is 
prevented,  which  in  these  classes  is  never  of  any  harm  to  the  individual. 

UNITING  OF  VAS  DEFERENS  ACCIDENTALLY  SEVERED 

In  case  a  vas  deferens  is  accidentally  severed  during  the  progress  of  any 
operation  it  may  be  united  by  passing  two  sutures  of  fine  double  chromic  cat- 
gut from  without  into  the  lumen  of  one  segment,  then  into  the  lumen  of  the 
other  segment,  then  out  through  its  wall  and  tying  loosely  one  on  each  side, 
and  then  applying  a  few  sutures  to  the  edges  of  the  vas. 

The  catgut  in  the  lumen  acts  as  a  splint  and  secures  a  continuous  passage 
through  the  vas. 

ABSCESS  OF  THE  SEMINAL  VESICLES 

In  many  cases  the  infection  is  limited  to  the  seminal  vesicles.  This  may 
be  unilateral,  or  it  may  affect  both  sides.  If  the  infection  has  become  chronic 
nothing  short  of  surgical  treatment  will  give  permanent  relief. 

Technique.  The  same  operation  must  be  performed  that  has  just  been 
described  as  prostatotomy,  differing  in  that  the  infected  vesicle  is  located  with 
the  finger  in  the  rectum,  and  that  it  is  carefully  and  thoroughly  removed  with 
a  moderately  sharp  curette.    The  space  is  then  drained  as  in  prostatotomy. 

CASTRATION 

This  operation  is  indicated  for  the  relief  of  malignant  disease  of  the  testicle, 
for  gangrene,  or  for  traumatism,  which  would  inevitably  result  in  gangrene 
of  the  organ,  for  destructive  suppuration,  and  for  very  extensive  unilateral 
tuberculosis. 


606  SURGERY  OF  THE  GENITO-URINARY  TRACT 

If  tuberculosis  occurs  in  both  organs  simultaneously,  or  in  the  remaining 
organ  after  the  other  has  been  removed  for  any  reason,  we  have  never  found 
it  necessary  to  perform  this  operation,  but  have  substituted  the  destruction 
of  the  diseased  portion  by  means  of  the  actual  cautery.  Even  in  cases  in 
which  only  a  very  slight  amount  of  the  tissue  may  be  preserved  we  have  found 
this  of  great  value  to  the  patient.  This  is  true  even  in  cases  in  which  it  was 
necessary  to  remove  the  epididymis,  together  -with  the  vas  deferens.  So  long 
as  it  was  possible  to  preserve  the  seminal  vesicles  there  has  been  no  mental 
depression  on  account  of  the  partial  destruction  of  the  testes  with  the  actual 
cautery,  together  with  the  removal  of  the  vas  deferens  on  both  sides.  It  is 
quite  different  in  case  of  double  castration  in  patients  too  young  to  have 
passed  beyond  the  virile  period  normally.  Double  castration,  in  our  experi- 
ence, has  resulted  in  permanent  relief  from  urinary  obstruction  due  to  hyper- 
trophy of  the  prostate  gland  in  about  fifty  per  cent,  of  all  cases  in  which  we 
have  made  use  of  this  method.  There  is,  however,  no  definite  guide  that  will 
indicate  which  cases  are  likely  to  be  benefited.  Moreover,  the  operation  results 
in  a  deformity  which  is  very  repulsive  to  many  patients,  even  though  past 
the  virile  stage. 

It  seems  as  though  this  method  should  receive  definite  recognition,  but 
since  perineal  prostatectomy  has  been  so  much  simplified,  and  its  safety  so 
greatly  enhanced,  it  appears  doubtful  whether  castration  for  the  relief  of 
prostatic  hypertrophy  will  continue  to  be  employed  to  any  great  extent. 

TUMORS  OF  THE  TESTICLE 

The  most  common  forms  of  tumor  of  the  testicle  are  sarcoma,  enchondroma 
and  teratoma.  All  other  forms  may  occur,  but  are  not  common.  Tumors 
should  be  differentiated  from  gumma,  inflammatory  swelling,  hydrocele  with 
an  unusually  tense  sac,  or  a  sac  which  has  undergone  calcareous  degeneration, 
scrotal  hernia  with  incarcerated  omentum,  tuberculosis  of  the  testicle  and 
epididymis  and  simple  hyperplasia  of  the  testicle. 

The  most  common  error  occurs  in  connection  with  gumma  of  the  testicle, 
which  is  not  a  very  unusual  condition.  It  is  frequently  necessary  to  place  the 
patient  under  vigorous  antisyphilitic  treatment  for  a  few  weeks  in  order  to 
positively  clear  up  the  diagnosis.  It  seems  wise  in  all  of  these  cases  to  test 
the  patient  carefully  with  salvarsan  before  making  a  positive  diagnosis  of  a 
malignant  growth,  as  this  remedy  acts  so  promptly  that  even  if  malignancy 
is  present  the  patient  will  lose  little  because  of  the  delay.  Tuberculosis  can 
usually  be  eliminated  more  easily  because  of  the  nodular  condition  of  the 
swelling  and  the  tendency  to  breaking  down  of  portions.  There  is  usually 
also  a  tubercular  history,  and  the  progress  of  the  disease  is  relatively  slow. 

The  differentiation  between  hernia  and  hydrocele  has  been  discussed  in 
connection  with  these  subjects. 

Technique.  An  incision  is  made  through  the  skin  from  the  external 
abdominal  ring  downward  to  a  point  near  the  lower  edge  of  the  scrotum; 
then  the  entire  organ,  together  with  the  tunica  vaginalis,  is  enucleated.  A 
pair  of  heavy  clamp  forceps  is  applied  .iust  outside  of  the  external  abdominal 
ring,  then  the  tissues  of  the  cord  are  dissected  out  in  the  inguinal  canal.  If 
the  tumor  is  quite  advanced,  the  incision  in  the  skin  may  be  carried  to  a  point 
opposite  the  internal  abdominal  ring,  and  may  be  carried  through  the  deep 
fascia  and  the  fascia  of  the  external  oblique  abdominal  muscle,  exposing  the 
tissues  of  the  cord  throughout  the  entire  distance  of  the  inguinal  canal.  In 
this  case  the  tissues  of  the  cord  are  dissected  out  to  this  point. 

The  vas  deferens  is  then  separated  from  the  remaining  tissues  of  the  cord, 
ligated  with  catgut,  cut  and  permitted  to  retract  within  the  internal  abdom- 


SURGERY  OF  THE  GENITO-URINARY  TRACT  607 

inal  ring.  The  remaining  structures  of  the  cord  are  then  separated  and  the 
various  larger  vessels  ligated  and  cut  separately  and  successively  permitted 
to  retract  beyond  the  internal  abdominal  ring.  Then  the  remaining  portion 
of  the  cord  is  ligated  en  masse  and  cut.  In  this  manner  one  may  easily  guard 
against  secondary  hemorrhage.  All  bleeding  points  are  carefully  caught  and 
ligated.  A  small  drain  is  inserted  in  the  lower  angle  of  the  wound  in  order 
to  prevent  the  accumulation  of  serum  from  the  large  surface.  The  wound  is 
then  sutured  and  an  ordinary  dressing  applied  and  held  in  place,  preferably 
by  a  properly  constructed  suspensory  bandage. 

If  the  malignant  growth  has  invaded  the  skin,  or  the  other  side  of  the 
scrotum,  the  same  should  be  entirely  removed,  provided  it  seems  likely  that 
the  disease  is  still  localized.  Unfortunately  metastases  usually  occur  in  these 
cases  before  they  have  advanced  to  the  point  of  invading  the  surrounding 
tissues ;  hence  the  prognosis  is  usually  hopeless  when  this  condition  is  present. 

If  the  operation  is  performed  without  unnecessary  traumatism,  it  is  usually 
not  followed  by  any  severe  degree  of  shock.  In  patients  advanced  in  age, 
however,  the  shock  is  sometimes  quite  considerable,  and  many  surgeons  have 
reported  the  occurrence  of  acute  melancholia,  which,  it  seemed,  was  not  due 
to  sepsis  in  some.  In  young  patients  this  operation  very  frequently  gives 
rise  to  mental  depression,  and  should  not  be  employed  if  there  is  any  possi- 
bility of  avoiding  it. 

In  some  cases  the  deformity  may  be  corrected  by  inserting  into  the  scrotum 
a  properly  shaped  mass  of  paraffin  or  a  hollow  structure  composed  of  celluloid 
of  the  same  form. 

One  of  these  devices  seems  to  be  of  considerable  value  to  neurotic  subjects, 
and  if  a  patient  seems  inclined  to  be  neurotic  it  may  be  well  to  make  use  of 
this  plan  at  the  time  of  the  original  operation. 


PART  IX 

SURGERY  OF  THE  FEMALE  PELVIS 


OVARIAN  TUMORS 


General  history.  The  early  history  in  cases  of  ovarian  tumors  is  usually 
negative,  the  growth  being  discovered  b}^  accident.  Among  educated  people 
in  the  higher  classes  of  society  such  a  tumor  is  usually  discovered  during  a 
careful  physical  examination  made  by  the  family  physician  in  the  course 
of  some  illness  of  the  patient  which  has  no  relation  to  the  presence  of  the 
tumor.  Thorough  physical  examinations  are  now  so  commonly  made  that 
in  this  class  of  patients  the  growth  is  usually  discovered  before  it  has  advanced 
to  any  great  size. 

It  is  quite  different  among  patients  belonging  to  the  so-called  lower  classes 
of  society.  Among  these  ovarian  tumors  are  usually  not  discovered  until 
they  have  attained  considerable  size,  when  the  patient  discovers  the  growth 
herself.  In  a  large  majority  a  history  of  peritonitis  at  some  time  in  the 
past  can  be  established,  provided  the  conditions  are  favorable  for  obtaining 
a  perfect  history.  In  many  cases  the  time  of  such  peritonitis  is  so  remote 
that  it  becomes  necessary  to  inquire  from  the  parents  regarding  the  patient's 
sickness  during  childhood. 

The  peritonitis  of  early  youth  and  childhood  is  usually  due  to  appendi- 
citis or  typhoid  fever,  and  occasionally  to  scarlet  fever.  Later  on  in  life  it  is 
more  commonly  dependent  upon  a  specific  infection  through  the  uterus  and 
tubes,  and  still  later  to  puerperal  infection  following  childbirth  or  abortion. 

These  infections  are  certain  to  leave  the  ovaries  covered  wuth  connective 
tissue  which  would  favor  the  formation  of  retention  cysts  in  the  Graafian 
follicles. 

Variety  of  cysts.  They  may  be  simply  retention  cysts  formed  by  the 
distension  of  Graafian  follicles  with  serum  secreted  from  the  lining  of  these 
follicles.  These  may  be  simple  or  multiple,  and  may  remain  small  or  they 
may  attain  enormous  size.  The  largest  one  we  have  encountered  weighed 
eighty-one  pounds  in  a  woman  weighing  seventy  pounds  after  the  tumor 
had  been  removed.  C^-^sts  of  this  variety  have,  however,  been  reported  much 
heavier. 

Again  the  epithelial  lining  of  the  Graafian  follicle  ma.v  take  upon  itself 
an  abnormal  development,  forming  a  papilloma  or  a  carcinoma.  In  this 
event  the  cyst  contains  gelatinous,  viscid  fluid.  The  papillomatous  or  carci- 
nomatous growths  may  perforate  the  cyst  wall  and  may  infect  the  peritoneum 
covering  the  intestines,  or  the  parietal  peritoneum,  and  then  the  free  peri- 
toneal cavity  may  contain  serous  or  gelatinous  fluid.  It  frequently  happens 
that  this  growth  invades  the  surrounding  organs  and  gives  rise  to  complica- 
tions which  are  always  serious  in  character  ultimately. 

Occasionally  a  portion  of  the  ovary  is  located  in  the  broad  ligament  and 
may  in  such  location  give  rise  to  the  formation  of  a  cyst  known  as  a  cyst 
of  the  broad  ligament,  or  intra-ligamentous  cyst, 

39 

609 


610 


SURGERY  OF  THE  FEMALE  PELVIS 


A  tumor  may  consist  of  a  simple  retention  cyst  in  one  part,  and  a  papil- 
lomatous cyst  in  the  remaining  portion. 

It  seems  likely  that  many  of  these  tumors  which  are  primarily  simple 
cysts,  later  on  degenerate  into  papillomatous  cysts,  and  these  in  turn  into 
carcinomatous  tumors. 

Diagnosis.  Small  ovarian  cysts  are  diagnosed  by  bimanual  examination. 
They  are  recognized  as  more  or  less  spherical  masses  located  in  the  pelvis. 
They  may  lie  to  the  right  or  left,  behind  or  in  front,  or  above,  the  uterus. 
Unless  there  has  been  a  recent  pelvic  peritonitis  they  are  likely  to  be  movable 
and  can  be  separated  from  the  uterus.  If  the  abdominal  walls  are  not  very 
thick  fluctation  can  usually  be  recognized.  Later  on  when  the  tumor  has 
attained  considerable  size  it  rises  in  the  pelvis  and  ultimately  is  forced  by 
its  size  to  occupy  the  abdominal  cavity  above  the  pelvis.    Fluctuation  can  now 


Specimen  Removed  in  a  Case  of  Bilateral  Papillocystadenoma  op  the  Ovaries. 
MENT — Panhysterectomy  with  Removal  of  Both  Tumors. 


Teeat- 


usually  be  established  across  the  abdomen.  The  tumor  displaces  the  intes- 
tines, consequently  percussion  over  its  most  prominent  portion  gives  rise  to 
a  dull  sound.  Above  and  to  either  side  there  is  resonance  because  of  the 
location  of  the  stomach  and  transverse  colon.  A  change  in  the  position  of 
the  patient  makes  no  change  in  the  percussion  sounds.  It  is  movable  unless 
strongly  adherent  on  account  of  peritonitis. 

Differential  diagnosis.  Early  in  the  disease  it  is  most  easily  confounded 
with  pediculated  fibroid  tumors  of  the  uterus.  The  latter  are,  however,  harder, 
more  closely  connected  with  the  uterus,  and  there  is  with  these  usually  a 
history  of  menorrhagia. 

Extra-uterine  pregnancy  ''^^Y  ^^  mistaken  for  ovarian  cyst  early  in  its 
development,  but  the  absence  of  menstruation  is  likely  to  clear  up  such  a 
diagnosis. 

Pyosalpinx  occasionally  simulates  an  adherent  ovarian  cyst,  but  its  loca- 
tion and  the  indications  of  a  more  or  less  septic  condition  usually  suffice  to 
determine. 


SUKGERY  OF  THE  FEMALE  PELVIS  611 

Later  on  abdominal  ascites  may  be  mistaken  for  an  ovarian  cyst.  An 
examination  of  the  urine  and  the  heart  will  establish  a  nephritic  or  cardiac 
cause  for  the  ascites.  In  the  physical  examination  it  ^vill  be  found  that  the 
area  of  dullness  varies  vrith  the  position  of  the  patient  in  abdominal  ascites, 
unless  this  is  due  to  tuberculosis  -with  the  presence  of  adhesions.  In  ascites 
the  tympany  is  usually  over  the  most  prominent  portion  of  the  abdomen 
while  in  ovarian  cyst  the  opposite  condition  obtains,  there  being  an  area  of 
dullness  over  the  most  prominent  portion  and  tympany  over  the  epigastric 
and  lumbar  regions,  and  a  change  in  position  does  not  greatly  change  the 
percussion  sounds. 

It  frequently  occurs  that  the  intra-abdominal  organs  are  completely  fixed 
by  the  presence'  of  adhesions  due  to  tubercular  peritonitis,  and  that  the  intes- 
tines and  omentum  form  a  wall  above,  and  the  peMc  organs  together  with 
the  sigmoid  flexure  of  the  colon  make  a  dam  below,  the  free  ascitic  fluid, 
causing  the  latter  to  become  encapsulated,  as  it  were,  between  the  abdominal 
wall  in  front  and  these  two  barriers  above  and  below.  In  such  cases  the 
percussion  sounds  are  quite  as  constant  as  in  the  presence  of  an  ovarian 
cyst,  making  the  differential  diagnosis  from  the  physical  examination  virtually 
impossible.  The  history  in  such  cases  will  show  that  the  intra-abdominal 
accumulation  was  diffuse  during  the  early  part  of  the  disease,  but  this  is 
not  always  observed,  because  the  surgeon  is  not  consulted  until  later.^  There 
is  also  an  evening  temperature  during  some  part  of  the  attack,  but  this  again 
is  not  always  observed,  and  when  the  patient  comes  under  the  observation 
of  the  surgeon  the  temperature  is  no  longer  abnormal. 

Obesity.  Every  year  we  have  a  number  of  patients  sent  with  a  rather 
acute  circumscribed  obesity  or  lipomatosis  of  the  lower  portion  of  the  anterior 
abdominal  wall,  with  the  request  to  remove  an  abdominal  tumor.  Usually  a 
diagnosis  of  ovarian  cyst  has  been  made  on  account  of  the  presence  of 
pseudo-fluctuation  in  this  mass.  The  patients  are  usually  obese,  but  the 
general  condition  thereof  is  slight  compared  with  the  local,  and  unless  one's 
attention  has  been  directly  called  to  this  a  mistaken  diagnosis  is  most  natural. 
This  can  be  avoided  by  grasping  the  mass  laterally  and  lifting  it,  which 
will  show  it  to  be  entirely  in  the  tissues  of  the  abdominal  wall  and  not  within 
the  abdominal  cavity. 

Hydronephrosis.  A  hydronephrosis  is  not  uncommonly  associated  with 
movable  kidney,  and  this  mobility  may  be  so  excessive  as  to  permit  the 
kidney  to  visit  almost  every  portion  of  the  abdominal  cavity,  and.  in  fact, 
it  may  be  so  movable  that  it  can  be  palpated  in  the  pelvis,  in  which  event  it 
may  be  mistaken  for  an  ovarian  cyst.  This  condition  is,  however,  uncommon. 
It  usually  begins  in  the  region  of  the  right  kidney;  there  is  irregularity  in 
the  size  of  the  tumor,  and  the  decrease  in  its  size  is  associated  with  the  free 
evacuation  of  urine.  The  tumor  can  be  replaced  in  the  right  hypochondriac 
region,  and  when  thus  replaced  the  alteration  just  spoken  of  is  liable  to  occur, 
because  this  disposes  of  the  acute  flexion  of  the  ureter.  There  are,  however, 
some  cases  in  which  it  will,  undoubtedly,  be  impossible  to  make  a  positive 
differential  diagnosis. 

Other  simulating  conditions.  A  movable  spleen,  or  liver,  has  occasionally 
been  mistaken  for  an  ovarian  cyst.  This  is  also  true  of  cysts  of  the  pancreas. 
Very  rarely  a  greatly  distended  gall  bladder  may  be  exceedingly  movable, 
in  fact,  quite  as  movable  as  a  hydronephrosis,  and  in  such  an  instance  it  may 
be  mistaken  for  an  ovarian  cyst. 

These  errors  in  diagnosis  are  much  more  common  in  patients  with  thick 
abdominal  walls.  The  fluctuation  which  is  due  to  the  fat  in  the  abdominal 
wall  frequently  causes  an  error  of  diagnosis  by  transmitting  the  sensation 
of  fluctuation  to  solid  masses,  such  as  the  liver  or  the  spleen. 


612 


SURGERY  OF  THE  FEMALE  PELVIS 


Occasionally  an  ovarian  cyst  has  a  pedicle  sufficiently  long  to  permit 
the  tumor  to  be  carried  to  anj^  part  of  the  abdominal  cavity,  and  then  it  is 
likel}^  to  be  mistaken  for  a  tumor  connected  with  some  organ  in  whose  vicinity 
it  happens  to  be  first  discovered.    In  one  instance  we  encountered  a  carcinoma 


Abdominal  Incision  through  the  Linea  Alba  between  the  Umbilicus  and  the  Pubis. 

Tho  deep  silk-n-orm  gut  sutures  being  in  place;  (a)  subcutaneous  fat;  (b)  deep  fascia 
composed  of  the  aponeurosis  of  the  internal  and  external  oblique  abdominal  muscles;  (c) 
the  rectus  abdominis  muscle;   (d)  the  peritoneum  and  transversaiis  fascia. 


of  the  pylorus  as  large  as  a  fist,  which  could  be  moved  to  every  portion  of  the 
abdominal  cavity  and  which  was  first  discovered  in  the  right  inguinal  region, 
and  was  mistaken  for  a  cyst  of  the  ovary. 

These  errors  are,  of  course,  quite  uncommon,  but  it  is  well  to  bear  in  mind 
the  possibility  of  their  occurrence. 


SURGERY  OF  THE  FECIALS  PELVIS  613 

Ovarian  cyst  with  twisted  pedicle.  At  times  an  ovarian  cyst  with,  a  long 
pedicle  may  develop  to  a  considerable  size  without  being  noticed,  until  by  some 
chance  the  pedicle  becomes  twisted  upon  itself  and  the  nutrition  of  the 
cyst  is  thus  suddenly  interrupted.  If  the  blood  vessels  are  entirely  occluded 
the  occurrence  is  likely  to  be  accompanied  by  severe  pain,  which  may  give 
rise  to  a  diagnosis  of  appendicitis,  rupture  of  extra-uterine  pregnancy,  gall 
stones,  or  renal  calculus  passing  through  the  ureter.  The  abdominal  walls 
are  usually  so  tense  after  such  an  happening  that  it  is  practically  impossible 
to  make  a  positive  diagnosis  without  the  use  of  general  anesthesia,  unless  the 
cyst  is  of  appreciable  size  and  the  abdominal  walls  thin.  The  presence  of 
a  tumor  will,  of  course,  clear  up  the  differential  diagnosis,  with  the  excep- 
tion of  extra-uterine  pregnancy,  which,  however,  is  characterized  by  increasing 
anemia,  and  within  a  few  hours  after  the  beginning  of  the  attack  it  is  usually 
possible  to  palpate  the  coagulated  blood  in  the  cul-de-sac  of  Douglas  by 
making  a  vaginal  examination.  This  coagulated  blood  has  a  peculiar,  doughy 
feeling,  which,  when  once  detected,  will  be  readily  remembered. 

Distended  urinary  bladder.  One  other  condition  has  been  mistaken  for 
an  ovarian  cyst  more  frequently  perhaps  than  any  other,  but  this  is  usuallj' 
the  result  of  carelessness  and  is  practically  always  cleared  up  before  an 
attempt  is  made  to  remove  the  cyst  by  means  of  an  operation,  because  it 
is  now  the  universal  practice  to  catheterize  the  urinary  bladder  before  under- 
taking an  abdominal  section.  It  has  frequently  happened  that  a  distended 
urinary  bladder  has  been  regarded  as  an  ovarian  cyst,  but  the  passage  of  the 
catheter  invariably  clears  up  this  diagnosis ;  and  a  surgeon  who  has  once 
experienced  this  blunder  will  recognize  it  in  future  cases  without  the  slightest 
difficulty. 

Impacted  feces  in  the  cecum  or  in  the  sigmoid  flexure  have  been  mis- 
judged for  ovarian  cyst.  The  free  catharsis  which  is  ordinarily  employed 
in  the  preliminary  treatment  of  these  cases  is  sure  to  clear  up  the  diagnosis. 

Dermoid  cysts  of  the  ovary.  The  ovary  may  contain  a  certain  amount  of 
epiblastic  tissue,  such  as  skin  with  hair  follicles  or  mucous  membrane  with 
embryonic  teeth,  or  these  may  exist  in  connection  with  bone,  connective  or 
glandular  tissue.  These  structures  may  remain  in  a  latent  state  for  a  long 
period  of  time,  and  may  then  begin  to  develop  into  what  are  technically  termed 
dermoid  cysts  because  of  the  hair  and  epithelium  and  teeth  which  they  are 
likely  to  contain.  Such  cysts  do  not  usually  develop  to  any  great  size.  They 
usually  contain  more  or  less  hard  tissue,  such  as  bone  or  cartilage,  and  are 
consequently  prone  to  give  rise  to  pain  on  account  of  pressure.  The  differential 
diagnosis  of  these  tumors  in  no  way  varies  from  that  in  ovarian  cysts,  and 
their  treatment  corresponds  to  the  treatment  of  the  latter;  consequently  it 
will  not  be  necessary  to  give  them  a  separate  discussion. 

Technique  for  the  removal  of  ovarian  cysts.  An  incision  is  made  in  the 
median  line,  between  the  umbilicus  and  the  pubis,  from  one  to  three  inches 
in  length.  "When  the  abdominal  cavity  has  been  opened  the  cyst  will  present 
as  a  bluish-white,  shining  surface.  If  the  cyst  is  simple  it  will  be  regular 
and  smooth  on  its  surface ;  if  multiple,  one  is  likely  to  observe  the  lobes  upon 
its  external  surface. 

If  the  cyst  is  simple,  it  is  best  to  withdraw  the  fluid  from  its  cavity  by 
means  of  a  large-sized  trocar,  which  is  plunged  into  it,  an  assistant  pressing 
the  abdominal  wall  gently  against  the  surface  of  the  cyst  in  order  to  prevent 
the  accidental  escape  of  any  fluid  into  the  free  abdominal  cavity. 

The  cystic  fluid.  The  fluid  contained  in  these  cysts  may  vary  in  color 
from  a  perfectly  clear,  limpid,  to  a  yellow  or  dark-colored  kind.  The  latter 
color  is  usually  the  result  of  a  hemorrhage  into  the  cavity  of  the  cyst  and 
ordinarily  occurs  in  those  which  have  been  subjected  to  some  form  of  trau- 


614  SURGERY  OF  THE  FEMALE  PELVIS 

matism,  such  as  a  blow  upon  the  abdomen.  Cysts  which  have  previously 
been  tapped  frequently  contain  dark-colored  lluid  because  of  some  hemorrhage 
which  has  taken  place  into  the  cavity  through  the  wound  made  ui  tapping. 
Many  cysts  contain  a  thick,  gelatinous  lluid,  which,  however,  is  present  usually 
only  in  case  the  lining  of  the  cyst  has  undergone  papillomatous  degenera- 
tion. The  substance  may  be  so  thick  that  it  cannot  be  forced  through  a 
trocar,  and  then  the  abdominal  wound  will  have  to  be  enlarged  so  that  tlie 
tumor  may  be  removed  entire.  This  gelatinous  fluid  often  contains  cells 
which  may  give  rise  to  the  formation  of  secondary  growths  upon  the  peritoneal 
surfaces,  consequently  it  is  wise  not  to  permit  any  of  it  to  get  into  the  free 
peritoneal  cavity. 

The  clear  fluid  contained  in  ovarian  cysts  is  sterile  and  harmless,  and 
its  introduction  into  the  peritoneal  cavity  does  not  result  in  any  harm  to 
the  patient. 

After  the  removal  of  the  contents  to  a  sufficient  extent  to  cause  the  cyst 
wall  to  become  less  tense  the  same  may  be  grasped  in  forceps  and  drawn 
partly  out  through  the  abdominal  wound,  thus  protecting  the  free  peritoneal 
cavity  against  the  introduction  of  any  fluid.  After  the  cyst  has  become 
entirely  empty  it  may  be  withdrawn  through  the  abdominal  wound  and  its 
pedicle,  consisting  of  the  broad  ligament  and  the  Fallopian  tube,  may  be 
transfixed  and  ligated  with  catgut  or  fine  silk,  and  then  the  tumor  may  be 
cut  away,  care  being  taken  to  leave  a  sufficient  amount  of  pedicle  beyond 
the  ligature  to  prevent  slipping. 

Throughout  the  operation  there  should  be  as  little  unnecessary  disturbance 
of  the  tissues  as  possible. 

The  stump  which  is  left  after  cutting  away  the  tumor  may  be  covered  with 
peritoneum  by  means  of  a  few  catgut  stitches.  It  is  supposed  that  this  will 
prevent  the  forming  of  adhesions  with  the  intestines,  but  we  believe  that  after 
an  aseptic  operation,  in  which  no  traumatism  is  inflicted  upon  any  of  the 
surrounding  tissues,  such  adhesions  practically  never  occur  even  if  the  stump 
is  not  covered  with  peritoneum ;  while  they  do  occur,  notwithstanding  this 
covering,  provided  the  operation  is  septic  or  traumatism  has  been  caused  to 
the  tissues. 

If  the  cyst  is  multiple,  composed  of  many  small  cysts,  the  trocar  may 
be  carried  from  one  to  the  other  of  these  without  being  withdrawn  from 
the  original  puncture,  provided  these  separate  cysts  are  large  enough  to 
make  such  practice  feasible.  If  the  cysts  are  too  small  it  is  better  to  enlarge 
the  abdominal  wound  sufficientlj^  to  permit  the  removal  of  the  tumor  in  toto. 
This  should  also  be  done  in  case  of  a  papillomatous  cyst,  or  one  containing 
fluid  too  thick  to  be  forced  out  through  the  trocar.  The  pedicle  of  such 
cysts  should  be  tied  and  the  tumor  removed  in  the  manner  described  for 
the  removal  of  simple  cysts. 

It  is  wise  always  to  examine  the  opposite  ovary  at  the  time  of  operation, 
because  it  frequently  happens  that  the  second  ovary  contains  a  small  cyst 
which,  if  left  undisturbed,  will  enlarge  and  require  a  second  abdominal  sec- 
tion. Should  the  fellow  ovary  contain  cysts  of  any  size  in  a  patient  over 
forty  years  of  age,  it  is  wise  to  remove  the  entire  organ,  together  with  the 
Fallopian  tube,  according  to  the  method  described.  In  a  younger  patient 
it  is  usually  better  to  leave  at  least  one-fourth  or  one-half  of  the  ovary,  mak- 
ing a  concial  excision  of  the  diseased  portion  and  closing  the  surface  caused 
by  this  excision  by  means  of  fine  catgut  stitches.  This  will  insure  the  nor- 
mal functions  of  the  ovary,  which  is  of  great  importance  to  a  young  patient. 
It  is  well  in  these  cases  to  examine  the  vermiform  appendix,  because 
remnants  of  disease  may  exist  in  this  organ  indicating  its  removal,  which 


SURGERY  OF  THE  FEMALE  PELVIS  615 

can  be  accomplished  without  danger  to  the  patient,  according  to  the  methods 
described  in  the  section  devoted  to  appendicitis. 

The  abdominal  wound  is  closed  in  the  usual  manner,  care  being  taken 
to  unite  corresponding  layers.  ^  ^       .   .  , 

It  is  our  practice  to  split  the  inner  fascia  of  the  rectus  abdominis  muscle 
on  each  side  and  to  unite  the  wound  by  inserting  deep  silk-worm  gut  sutures 
grasping  the  layers  down  to  the  transversal  is  fascia,  and  then  applying  a 
separate  row  of  continuous  catgut  sutures  to  the  peritoneum  and  trans- 
versalis  fascia,  uniting  the  recti  muscles  with  a  few  interrupted  catgut  sutures ; 
then  uniting  the  deep  fascia,  the  aponeurosis  of  the  external  and  internal 
oblique  muscles,  by  means  of  a  continuous  catgut  suture;  then  tying  the 
silk-worm  gut  sutures  and  applying  a  row  of  coaptation  stitches  to  the  skm, 
as  illustrated  in  suture  of  the  abdominal  w^ound  elsewhere  herein. 

Complications.  The  most  common  complication  of  ovarian  cysts  affecting 
the  method  of  operation  is  the  presence  of  adhesions.  These  may  exist  between 
the  ovarian  cyst  and  any  one  or  more  of  the  intra-abdominal  organs.  The 
most  common  adhesions  are  to  the  omentum,  the  anterior  abdominal  wall, 
and  to  the  intestines.  It  does  not  matter  to  what  portion  an  ovarian  cyst 
may  be  adherent,  it  is  always  wise  to  expose  the  adhesion  before  an  attempt 
is  made  to  dispose  of  it,  because  although  it  may  occasionally  become  neces- 
sary to  lengthen  the  abdominal  incision  for  this  purpose,  still  this  is  of  slight 
importance  as  compared  to  the  benefit  the  patient  derives  from  having  this 
portion  of  the  operation  performed  in  plain  sight.  These  adhesions  fre- 
quently contain  very  large  veins  and  their  injury  results  m  a  great  loss  of 
blood,  which  is  in  itself  undesirable  and  complicates  the  operation  by  cover- 
ing the  tissues  so  that  they  can  be  recognized  with  less  ease.  It  is  usually 
best  to  grasp  long  adhesions  between  two  pairs  of  forceps,  to  cut  between 
these  and  to  ligate  the  portion  which  is  not  connected  with  the  ureters,  and 
then 'drop  the  adhesions  into  the  abdominal  cavity.  If  the  adhesion  is  to 
the  intestine  or  other  abdominal  organ  it  is  usually  possible  to  select  a  point 
at  which  these  tissues  can  readily  be  separated  from  each  other,  because 
there  seems  to  be  a  union  between  the  peritoneal  surfaces  which  is  not  farm 
and  can  easily  be  disturbed  if  one  succeeds  in  finding  the  point  of  cleavage. 
It  is  well  to  cover  at  once  with  peritoneum  any  abraded  surface  which  is 
caused  by  this  separation,  so  as  to  prevent  future  adhesions.  This  is  espe- 
cially important  if  the  abraded  surface  is  on  the  intestine.  If  this  precaution 
is  not  observed  a  perforation  may  readily  occur. 

ABDOlVnNAL  HYSTERECTOMY 

Principles.  The  removal  of  the  uterus  is  in  itself  one  of  the  simplest  and 
safest  abdominal  operations  in  cases  in  which  the  condition  for  which  the 
operation  is  performed  is  not  connected  with  troublesome  complications.  The 
success  of  the  operation  depends  upon  the  appreciation  of  a  few  exceedingly 

In  this  operation,  as  in  every  other  abdominal  one,  the  first  principle  is, 
of  course  the  prevention  of  infection.  This  may  be  accomplished  very  easily, 
as  the  only  source  of  infection  connected  with  the  operation  itself  is  the 
uterine  canal,  and  infection  from  this  may  easily  be  avoided  with  care. 

The  next  important  point  to  be  observed  is  the  control  of  hemorrhage. 
The  uterus  is  supplied  with  blood  by  two  small  arteries  on  each  side ;  the 
ovarian  approaching  it  through  the  upper  part  of  the  broad  ligament  on 
each  side,  and  the  uterine  artery  approaching  it  from  each  side  lower  down. 
These  vessels  are  ordinarily  not  larger  than  a  good-sized  knitting  needle 
and  are  consequently  of  no  importance,  provided  they  are  recognized  and 


616 


SURGERY  OF  THE  FEMALE  PELVIS 


carefully  ligated.  The  method  to  be  employed  for  the  control  of  hemorrhage 
will  depend  upon  the  choice  of  plan  for  removal;  with  the  uterus,  the  Fallo- 
pian tubes  and  ovaries,  which  is  always  indicated  in  patients  over  forty 
years  of  age ;  or  the  removal  of  the  uterus  without  the  ovaries  and  tubes, 


^x-t 


Abdominal  Hysterectomy. 

a  uterus;  6  forceps  on  broad  ligament;  c  Fallopian  tube;  d  forceps  on  uterine  side  of 
broad  ligament;  e  forceps  on  ovarian  side  of  broad  ligament;  /  bladder;  i  round  ligament; 
o  ovary. 

indicated  in  younger  patients  in  whom  these  organs  in  themselves  are  not 
diseased. 

Technique.  If  the  ovaries  and  tubes  are  to  be  removed  with  the  uterus,  two 
pairs  of  long-jawed,  strong  hemostatic  forceps  should  be  applied  to  the  broad 
ligament,  side  by  side,  just  externally  to  the  ovary.  They  should  extend  par- 
allel to  each  other  with  a  space  of  one-half  to  three-fourths  of  an  inch  between 


SURGERY  OF  THE  FEMALE  PELVIS 


617 


them.  The  points  of  these  forceps  should  extend  to  the  body  of  the  uterus. 
This  should  be  done  alike  on  both  sides ;  then  the  tissues  between  these  for- 
ceps is  severed  and  the  uterus,  ovaries  and  tubes,  grasped  by  the  two  pairs 
of  forceps  which  are  nearest  together,  can  be  elevated.    The  broad  ligament 


r 


Abdominal  Hysterectomy. 

b  posterior  flap  of  uterine  stump;  c  anterior  flap  of  uterine  stump;  d  forceps  on  uterine 
artery;  e  forceps  on  broad  ligament;  /  bladder;  i  round  ligament;  j  peritoneal  flap  for  cover- 
ing stump  of  uterus;  g  colon.  The  suture  grasping  tissues  b  and  c  should  be  peritoneal  flap 
/  instead. 

is  then  severed  farther  down  toward  the  cervix,  until  the  uterine  artery  is 
exposed.  This  is  grasped  by  a  separate  pair  of  forceps  on  each  side;  then 
the  peritoneal  flap  is  cut  from  the  anterior  surface  of  the  uterus  and  dissected 
downwards  until  a  point  opposite  the  internal  os  is  approached.  The  uterus 
is  then  cut  away  by  means  of  a  conical  incision.     This  leaves  the  mucous 


618 


SURGERY  OF  THE  FEMALE  PELVIS 


membrane  lining  the  cervix  at  the  bottom  of  a  conical  space.  It  is  necessary 
to  exercise  great  care  in  cutting  down  upon  the  uterine  arteries  in  order  to 
approach  them  on  each  side  of  the  body  of  the  uterus  after  they  have  escaped 
from  the  broad  ligaments.     If  this  precaution  is  not  taken  there  is  danger 


Abdominal  Hysterectomy. 

b  suture  closing  in  entire  surface  with  peritoneum ;  c  Fallopian  tube ;  /  bladder ;  j  flaps 
of  uteru!^;  g  colon;  o  ovary.  To  the  right  the  plate  shows  the  ovary  and  tube  removed;  to 
the  left  they  have  been  preserved. 

of  injuring  the   ureters,  which  pass  through  the  broad  ligament  near  this 
point. 

If  the  operation  is  performed  for  the  removal  of  a  myomatous  uterus 
great  care  must  be  taken  in  making  the  anterior  peritoneal  flap,  because  it 
frequently  happens  that  the  bladder  is  carried  a  considerable  distance  up 
over  the  anterior  surface  of  such  a  uterus,  and  if  care  is  not  exercised  in 
performing  this  part  of  the  operation  this  organ  is  likely  to  be  injured. 


SURGERY  OF  THE  FEi\IALE  PELVIS  -         619 

It  is  necessary  to  be  careful  in  sponging  the  surface  of  the  uterine  stump 
not  to  carry  any  infectious  material  in  the  mucous  membrane  lining  this 
stump  to  other  portions  of  the  abdominal  cavity,  thus  causing  infection. 
For  the  same  reason  it  is  "well  to  eliminate  this  remnant  of  the  canal  from 
the  operation  by  applying  catgut  stitches  to  unite  the  sides  of  the  conical 
cavity  which  has  been  formed.  It  is  this  part  of  the  operation  which  should 
be  done  with  especial  care,  because  most  deaths  occurring  after  abdominal 
hysterectomy  are  due  to  gangrene  of  the  uterine  stump,  which  results  from 
a  faulty  application  of  the  sutures.  During  the  early  practice  of  this  opera- 
tion surgeons  were  taught  to  fear  hemorrhage  following  hysterectomy,  and 
consequently  most  of  the  older  surgeons  acquired  the  habit  of  tying  the 
sutures  applied  to  the  stump  so  tightly  as  to  make  gangrene  thereof  a  very 
common  occurrence.  These  sutures,  and,  in  fact,  all  of  the  sutures  uniting 
the  surface  in  hysterectomy,  should  be  tied  just  sufficienth^  firm  to  bring 
the  surfaces  together,  but  not  so  firm  as  to  cause  pressure-necrosis.  (The  ob- 
servation of  this  precaution  in  our  own  practice  has  reduced  the  mortality  in 
abdominal  hysterectomy  to  almost  nothing.) 

During  the  past  few  years  we  have  abandoned  the  plan  of  suturing 
the  tissues  of  the  uterine  stump  and  have  simply  covered  this  stump  by  apply- 
ing fine  catgut  sutures  to  the  peritoneum,  thus  carefully  covering  the  raw 
surface  of  the  stump.  In  this  way  the  danger  from  pressure  necrosis  of 
the  part  is  entirely  eliminated  and  the  operation  becomes  as  safe  as  a  simple 
ovariotomy  or  appendectomy. 

The  broad  ligament  is  now  transfixed  with  a  catgut  or  fine  silk  stitch 
and  ligated  on  each  side,  care  being  taken  to  apply  this  ligature  so  that 
there  is  no  possibility  of  slipping.  Then  a  stitch  is  placed  around  the  uterine 
artery  on  each  side  and  tied  only  just  firm  enough  to  prevent  hemorrhage. 
Then  it  is  our  practice  to  apply  a  separate  ligature  to  the  end  of  the  uterine 
artery  grasped  by  the  forceps  on  each  side.  This  does  not  seem  necessary, 
but  we  continue  to  do  this  as  a  result  of  the  old  superstition  concerning  the 
likelihood  of  hemorrhage. 

The  entire  wound  should  now  be  sutured  from  side  to  side,  so  that  every 
portion  is  covered  with  peritoneum.  This  completes  the  very  simple  opera- 
tion ;  the  four  points  to  be  borne  in  mind  being : 

1.  The  avoidance  of  infection. 

2.  The  protection  of  the  ureters  and  bladder, 

3.  The  careful  control  of  hemorrhage. 

4.  And  (most  important  of  all)  the  prevention  of  gangrene  of  the  stump 
by  avoiding  too  firm  tying  of  sutures. 

In  order  to  prevent  this  most  serious  complication  we  now  never  pass 
sutures  through  the  muscle  of  the  uterine  stump  but  simply  cover  the  stump 
with  peritoneum  from  the  loose  portion  in  front  which  is  sutured  to  the  peri- 
toneum on  the  posterior  surface.  If  the  uterine  arteries  have  been  ligated 
as  indicated  above  there  is  never  any  danger  from  hemorrhage  and  these 
patients  make  quite  as  smooth  a  recovery  as  after  a  simple  ovariotomy. 

In  order  to  obtain  a  good  floor  of  the  pelvis  which  will  prevent  prolapse 
of  the  stump  we  suture  the  ends  of  the  broad  ligaments  and  those  of  the 
round  ligament  over  the  stump,  thus  making  a  perfect  truss  for  the  sup- 
port of  the  pelvic  floor. 

The  sutures  used  are  ordinary  catgut  reinforced  by  a  few  of  fine  chromic 
catgut  for  the  broad  and  the  round  ligaments. 

In  case  it  is  desirable  to  remove  the  ovaries  and  tubes  the  operation 
is  done  in  the  same  manner,  with  the  exception  that  the  control  forceps 
are  applied  to  the  broad  ligament  directly  along  the  side  of  the  uterus,  leav- 
ing the  ovaries  and  tubes  to  the  outer  side  of  the  other  forceps. 


620 


SURGERY  OF  THE  FEMALE  PELVIS 


SPLITTING  OF  THE  UTERUS 


If  it  is  difficult  or  impossible  to  apply  the  forceps  to  the  broad  ligaments 
because  of  the  presence  of  tumors  or  adhesions,  or  both,  conditions  which 
occur  occasionally,  the  operation  may  be  greatly  facilitated  by  inserting  a 
strong  pair  of  tenaculum  forceps  in  each  horn  of  the  uterus,  having  an  assist- 


Eadiograph  of  Female  Pelvis. 

"  A  "  and  "  B  ",  calcareous  myomata  of  the  uterus.     "  C ' 
careous  iliac  lymph  gland. 


calcareous  ovary,  "  D  "  cal- 


ant  make  firm  traction  upon  these,  and  then  splitting  the  uterus  longi- 
tudinally down  to  a  point  opposite  the  internal  os.  The  tension  upon  the 
forceps  in  the  horns  of  the  uterus  prevents  hemorrhage  from  the  cut  sur- 
faces. 

Of  course,  the  same  precaution  must  be  used  against  injuring  the  blad- 
der on  the  anterior  surface  of  the  uterus,  if  it  extends  above  the  normal  posi- 
tion, that  was  mentioned  in  the  operation  just  described. 

When  the  internal  os  has  been  reached  a  slight  lateral  incision  is  made  on 


SURGERY  OF  THE  FEMALE  PELVIS  621 

one  side  to  a  point  at  which  the  uterine  artery  is  exposed.  The  broad  liga- 
ment, together  with  the  uterine  artery,  is  then  grasped  from  below  by  means 
of  strong  forceps,  and  the  uterus  is  cut  away  to  the  inner  side  of  these 
forceps.  Another  pair  of  tenaculum  forceps  is  inserted  in  the  lower  end  of 
the  half  of  the  uterus  under  consideration,  and  tension  made  upon  this,  as 
well  as  upon  the  tenaculum  forceps  in  the  horn  of  the  uterus  on  this  side. 
Care  must  be  taken  not  to  relax  upon  the  other  pair  of  tenaculum  forceps' 
for  fear  of  causing  a  hemorrhage  upon  the  half  of  the  uterus  not  immediately 
under  consideration. 

After  the  lower  end  of  the  uterus  has  been  loosened  it  is  an  easy  matter 
to  grasp  the  remaining  vessels  in  the  broad  ligament  by  means  of  clamps, 
and  remove  the  half  of  the  uterus  together  with  the  tumor  it  may  contain. 
If  the  Fallopian  tube  or  ovary  are  also  in  a  pathological  condition  they  can 
readily  be  removed  with  this  portion  of  the  uterus.  The  same  steps  are  taken 
upon  the  opposite  side. 

After  the  uterus  has  been  removed  the  vessels  are  ligated  precisely  as 
in  the  operation  which  has  just  been  described.  The  stump  of  the  uterus 
is  disposed  of  in  the  same  manner,  and,  in  fact,  the  remainder  of  the  opera- 
tion is  in  no  way  different  from  that  which  has  just  been  outlined. 

Adhesions.  If  there  are  adhesions  between  the  uterus,  or  the  ovaries  and 
tubes,  and  some  other  abdominal  organs,  these  must  be  loosened  with  great 
care  and  all  bleeding  points  properly  ligated,  and  all  abraded  surfaces  care- 
fully covered  with  peritoneum  by  means  of  Lembert  sutures.  Especial  pains 
must  be  taken  in  covering  large  abrasions  upon  the  small  intestine,  due  to 
the  necessity  of  loosening  extensive  adhesions.  Whenever  possible  it  is  wise 
to  make  transverse  closures  of  these  abraded  surfaces  for  fear  of  causing 
a  narrowing  of  the  small  intestine,  Avhich,  however,  is  not  very  likely  to 
occur  because  of  the  elasticity  of  the  peritoneum.  If  any  abraded  surface 
in  the  pelvis  cannot  be  covered  with  peritoneum  it  is  wise  to  place  the  sigmoid 
flexure  upon  this  surface,  and,  if  necessary,  to  fasten  it  by  a  few  fine  catgut 
stitches.     The  abdominal  wound  is  closed  in  the  usual  manner. 

MYOMECTOMY 

Generally  speaking  it  is  proper  to  make  a  hysterectomy  for  any  cases 
of  fibroid  tumor  of  the  uterus  in  patients  of  forty  j^ears  of  age  or  over,  in 
whom  this  operation  seems  to  require  the  least  amount  of  traumatism.  In 
younger  patients,  whenever  possible,  the  excision  of  fibroid  tumors  of  the 
uterus,  without  the  removal  of  the  uterus  itself,  should  be  practised,  even 
though  the  operation  be  connected  with  greater  difficulty  and  with  greater 
traumatism.  It  is  surprising  how  easily  fibroid  tumors  may  be  enucleated 
from  the  uterus  even  when  deeply-seated,  and  if  traction  is  made  upon  the 
organ  this  operation  is  not  connected  with  much  hemorrhage. 

If  the  tumor  is  in  the  superior  portion  of  the  uterus  the  transverse  incision 
should  be  made  and  the  tumor  enucleated.  Here  again  the  same  principle 
should  be  applied  that  has  been  mentioned  in  connection  with  the  closure 
of  the  stump  in  abdominal  hysterectomy.  The  space  from  which  the  tumor 
has  been  removed  should  be  closed  by  means  of  fine  catgut  sutures  which 
are  tied  just  firmly  enough  to  bring  the  surfaces  together,  but  not  sufficiently 
firm  to  cause  pressure-necrosis.  As  many  rows  of  these  sutures  as  are  required 
to  close  the  entire  cavity  should  be  employed;  their  number  is  of  no  special 
importance. 

AA^hen  the  outer  wound  in  the  surface  of  the  uterus  is  reached  it  is  impor- 
tant to  extend  the  suturing  a  little  beyond  each  end  of  the  wound,  because 


622  SURGERY  OF  THE  FEMALE  PELVIS 

this  will  overcome  the  troublesome  oozing  which  frequently  occurs  from  the 
very  ends  of  the  incision. 

If  the  uterine  cavity  is  opened  during  the  operation,  it  should  be  care- 
fully sponged  or  curetted  and  a  folded  piece  of  rubber  protective  tissue 
passed  through  the  uterine  canal  into  the  vagina  for  the  purpose  of  drainage. 
In  this  case  the  first  row  of  sutures  should  pass  down  to,  but  not  through,  the 
mucous  membrane,  for  fear  of  infecting  the  deeper  tissues  in  the  uterus. 
The  danger  of  infection  from  the  uterine  canal  in  these  cases  has  been 
greath'  over-estimated,  and  we  believe  that  in  eases  in  which  there  has 
apparently  been  such  an  infection  it  has  resulted  from  the  fact  that  the 
sutures  which  were  applied  for  the  purpose  of  protecting  the  wound  in  the 
uterus  were  tied  too  firmly  and  gave  rise  to  pressure-necrosis.  In  case  a 
large  fibroid  has  developed  in  the  broad  ligament,  so  that  after  its  removal 
there  remains  a  large  raw  surface,  this  should  be  covered  with  peritoneum, 
but  if  the  uterine  cavity  has  been  opened  during  the  operation,  or  if  the 
rectum  or  the  sigmoid  fiexure  have  been  disturbed,  it  is  best  to  insert  a  small 
glass  drain  or  a  cigarette  drain  into  the  angle  of  the  broad  ligament  next 
to  the  uterus  and  to  permit  this  to  pass  out  of  the  lower  angle  of  the  abdom- 
inal wound.    It  may  be  removed  in  two  to  five  days. 

PYOSALPINX 

Clinical  example.  This  is  typical  of  the  disease  under  consideration.  The  patient  is 
twenty-three  years  of  age,  married  fourteen  months,  and  gives  the  following  history: 

She  suffered  from  mild  attacks  of  all  the  contagious  diseases  of  childhood,  but  experienced 
no  unfavorable  after-effects.  Menstruation  began  at  the  age  of  fourteen,  was  regular  and 
painless,  and  the  patient 's  health  was  excellent  until  a  short  time  after  her  marriage,  when 
she  suddenly  experienced  severe  pain  in  the  lower  portion  of  her  abdomen.  She  had  previously 
observed  the  presence  of  leucorrhea  and  a  mihl  attack  of  cystitis,  to  which  she  gave  no  atten- 
tion. After  remaining  quiet  for  two  days,  taking  hot  douches  and  a  cathartic  and  applying 
heat  to  the  abdomen,  the  pain  subsided  and  she  was  able  to  be  up  and  about,  but  since  that 
time  she  has  never  felt  perfectly  strong  and  well.  Her  next  menstrual  period  was  characterized 
by  severe  pain,  lasting  for  two  days  and  leaving  her  slightly  worse  than  before.  She  felt 
feverisli  during  the  entire  period  of  menstruation.  She  has  continually  grown  worse,  sutt'ering 
from  severe  pain  every  few  days,  and  during  each  successive  menstrual  period  having  an 
attack  more  severe  than  the  preceding.  During  the  past  two  months  she  has  scarcely  recovered 
from  the  effects  of  one  attack  before  experiencing  the  next.  At  the  time  of  her  marriage  she 
was  strong  and  vigorous  and  in  every  way  in  excellent  health. 

Present  condition.  Anemic,  somewhat  emaciated,  having  lost  twenty  pounds  during  the 
past  yjar.  Her  appearance  indicates  that  she  has  suffered  severely.  Skin  is  rough  and  her 
color  is  bad. 

Physical  examination.  All  organs,  with  the  exception  of  the  pelvic,  are  normal.  A  pelvic 
examination  reveals  the  presence  of  severe  induration  throughout  the  pehic  floor.  In  the 
left  broad  ligament  there  is  a  mass  as  large  as  a  man's  fist.  The  right  broad  ligament  contains 
a  mass  about  one-half  as  large.  The  cervix  of  the  uterus  is  enlarged  to  twice  the  normal  size; 
it  is  hard  and  edematous.  Bimanual  examination  seems  to  reveal  a  slight  amount  of  fluctuation 
in  the  left  side. 

Upon  rectal  examination  there  is  found  an  indurated  area  opposite  the  cul-de-sac  of 
Douglas,  which  renders  this  portion  of  the  bowel  quite  rigid.  The  patient  complains  severely 
of  pain  during  l)oth  the  rectal  and  vaginal  examinations.  Upon  bimanual  examination  the 
abdominal  muscles  contract  to  protect  the  inflamed  tissues  underneath. 

Diagnosis.  The  history,  as  well  as  the  physicial  investigation,  indicate 
the  presence  of  an  infection  involving  the  uterus.  Fallopian  tubes  and  pelvic 
peritoneum.  This  is  undoubtedly  gonorrheal  in  origin,  because  of  the  time 
of  its  occurrence,  the  presence  of  leucorrhea  and  cystitis,  and  the  physicial 
evidences. 

Upon  inquiry  we  have  determined  that  the  husband  suffered  from  an 
acute  specific  urethritis  two  years  ago,  from  which  he  recovered  after  four 
months,  but  that  he  occasionaly  noticed  a  sliorht  amount  of  secretion  after 
some  indiscretion  in  diet  or  over-exertion.     About  one  week  after  his  mar- 


SURGERY  OF  THE  FEMALE  PELVIS  623 

riage  he  noticed  a  slight  recurrence  of  this  condition,  which,  however,  disap- 
peared after  a  few  days. 

It  is  likely  that  the  infection  advanced  slowly  through  the  uterine  canal 
and  through  the  Fallopian  tubes  and  that  the  fimbriated  extremities  of  the 
latter  organs  have  become  adherent  to  the  ovaries  and  thus  become  occluded, 
and  that  pus  has  accumulated  in  the  distended  Fallopian  tubes. 

The  patient  has  received  local  treatment  almost  constantly  since  the  begin- 
ning of  her  illness,  by  means  of  hot  douches,  the  application  of  tincture  of 
iodine  and  nitrate  of  silver  to  the  uterine  canal  and  the  cervix,  and  by  the 
application  of  vaginal  pads  saturated  with  glycerine  and  ichthyol;  but  none 
of  these  remedies  has  been  of  any  permanent  benefit. 

Medical  treatment.  During  the  early  part  of  the  disease  it  is  best  to  make 
Qse  of  non-surgical  means. 

1st.  Because  many  severe  infections  of  this  form  recover  completely 
under  this  treatment  and  later  go  through  normal  pregnancies  provided  rein- 
fection is  avoided. 

2nd.  Because  surgical  treatment  is  exceedingly  dangerous  during  the 
early  portion  of  the  disease,  while  it  is  quite  safe  later  on. 

3rd.  The  patient  is  not  exposed  to  any  risk  because  of  the  postponement 
of  operation,  provided  the  internal  treatment  is  carried  out  properly  and  rest 
in  bed  is  insisted  upon. 

The  infection  affects  a  relatively  small  and  safe  portion  of  the  peritoneal 
cavity — the  pelvic  portion.  If  it  is  confined  to  this  region  the  worst  possible 
consequence  will  be  a  circumscribed  abscess  which,  from  its  location,  may 
either  become  absorbed,  or  remain  encapsulated,  or  it  may  rupture  into  the 
rectum,  the  bladder  or  the  vagina.  If  undisturbed  the  rupture  will  practically 
always  take  place  into  the  rectum  if  it  occurs  at  all,  which  is,  of  course,  the 
most  favorable  direction. 

The  circumscribed  infection.  Anatomically  the  arrangement  is  most  per- 
fect for  the  development  of  circumscribed  abscesses. 

If  the  infection  advances  slowly  the  fimbriated  extremities  of  the  Fallo- 
pian tubes  will  become  adherent  to  the  ovaries  or  to  the  floor  of  the  pelvis,  and 
then  the  infection  will  be  confined  to  one  or  to  both  tubes.  It  may  remain  in 
this  position,  dilating  the  tubes  until  they  attain  a  considerable  size,  or  they 
may  become  distended  beyond  their  capacity  and  rupture  and  infect  the  sur- 
rounding tissues.  In  this  event  adhesions  have  usually  formed  before  the 
rupture  takes  place.  These  most  commonly  exist  between  the  tube  and  the 
omentum  or  cecum,  or  sigmoid  flexure  of  the  colon,  or  some  loop  of  the  small 
intestines,  or  several  or  all  of  these.  It  is  very  seldom  that  an  abscess  of  this 
kind  ruptures  into  the  free  peritoneal  cavity  except  as  the  result  of  a  severe 
strain  or  a  traumatism. 

With  a  circumscribed  infection  the  conditions  are  very  similar  to  those 
described  with  the  infection  due  to  perforative  or  gangrenous  appendicitis, 
and  consequently  the  early  treatment  should  have  the  same  end  in  view  as  has 
the  non-surgical  treatment  of  acute  appendicitis,  namely,  the  confinement  of 
the  infection  to  the  vicinity  of  the  tissues  originally  involved. 

The  physiological  elimination  of  the  infected  area  in  the  condition  under 
consideration  is  almost  perfect  because  the  omentum  will  apply  itself  to  the 
surface  of  the  tube,  the  sigmoid  flexure  will  apply  itself  above  and  to  the 
left,  and  the  cecum  and  appendix  to  the  right.  If  there  is  still  a  small  area 
left  it  will  be  occupied  by  some  portion  of  the  small  intestine,  and  as  all  of 
the  tissues  which  have  been  mentioned,  except  the  small  intestine,  are  rela- 
tively fixed,  the  infection  is  likely  to  remain  circumscribed  unless  it  is  carried 
by  the  small  intestine  from  its  original  area  to  other_  portions  of  the  peri- 
toneal cavity.    This  can  be  prevented  by  inhibiting  peristaltic  motion,  which, 


624 


SURGERY  OF  THE  FEMALE  PELVIS 


as  has  been  shown  before,  may  be  accomplished  by  the  prohibition  of  all  food 
and  cathartics  by  mouth  and,  if  necessary,  by  the  addition  of  the  use  of 
opium.  If  the  stomach  contains  food  or  mucus  this  should  be  removed  by 
gastric  lavage. 

It  should  be  remembered  that  where  neither  food  nor  cathartics  are  given 
by  mouth,  opiates  may  be  administered  either  by  enemata  or  hypodermatically 
with  safety,  to  the  patient. 

Large,  hot,  vaginal  douches  frequently  administered  are  a  source  of  great 
comfort  and  are  of  undoubted  benefit  to  these  patients.     The  douches  should 


^ 


Forms  of  Irrigation  Apparatus  Useful  in  Eectal  Feeding,  Etc. 


be  given  as  hot  as  they  can  be  borne.  The  patient  may  be  nourished  by  the 
use  of  nutritive  enemata,  which  have  been  described  herein  before. 

There  is  an  important  advantage  in  first  treating  all  cases  of  this  class  by 
the  method  just  described,  aside  from  those  mentioned  early  in  the  considera- 
tion of  this  subject,  owing  to  the  fact  that  the  virulence  of  the  micro-organisms 
causing  this  infection  will  be  very  greatly  reduced  if  the  infection  is  com- 
pelled to  remain  circumscribed ;  in  other  words,  we  make  use  of  the  principle 
of  rest  in  the  treatment  of  this  infectious  disease  the  same  as  we  do  in  the 
treatment  of  like  conditions  in  other  parts  of  the  body.  If  this  state  of  rest 
is  continued  for  a  time  the  infection  becomes  so  thoroughly  circumscribed 
that  the  pus  itself  will  ultimately  destroy  all  of  the  micro-organisms  which 
it  contains,  and  when  examined  will  be  found  perfectly  sterile. 

An  operation  performed  after  the  pus  has  acquired  this  condition  of 
sterility  is  of  course  relatively  very  much  safer  than  if  done  while  the  pus  is 


SUEGERY  OF  THE  FEMALE  PELAIS  625 

still  full  of  living  pathogenic  micro-organisms.  It  is  likely  that  in  many  cases 
in  which  it  was  supposed  that  a  re-infection  took  place  from  the  pus  that 
existed  in  a  circumscribed  abscess,  there  was  in  fact  a  re-infection  through 
the  uterus.  The  occurrence  of  such  re-infection  should,  of  course,  be  care- 
fully guarded  against. 

Although  a  large  majority  of  cases  in  which  there  is  but  a  single  infection 
of  the  Fallopian  tubes  will  recover  fully,  or  to  such  an  extent  that  it  is  impos- 
sible to  determine  the  presence  of .  any  pathological  condition  by  physical 
examination,  there  vnll  always  be  many  who  have  either  had  repeated  infec- 
tions or  have  not  recovered  fully  from  a  single  infection,  and  these  cases  can 
be  relieved  permanently  only  by  surgical  operation. 

Operative  technique.  The  operative  treatment  must  be  planned  so  that 
none  of  the  clean  portions  of  the  abdominal  cavity  become  infected  during 
operation,  so  that  all  of  the  disease  is  removed,  and  so  there  will  be  no  serious 
secondary  conditions  developed  as  the  result  of  the  operation. 

To  prevent  the  infection  of  portions  of  the  peritoneal  cavity  not  involved, 
it  is  wise  to  make  the  abdominal  incision  sufficiently  long  to  enable  the  sur- 
geon to  perform  the  necessary  manipulations  in  sight.  In  severe  cases  it  is 
usually  best  to  make  the  incision  from  a  point  an  inch  below  the  umbilicus 
to  the  pubis.  In  mild  cases  it  may  be  considerably  shorter.  In  unusually 
severe  ones  it  is  often  best  to  carry  the  incision  around  the  umbilicus  to  the 
left  and  a  convenient  distance  above  the  same. 

The  operation  can  be  greatly  facilitated  by  placing  the  patient  in  the 
Trendelenburg  position,  by  elevating  the  foot  of  the  table  so  that  the  patient's 
body  rests  at  an  angle  of  about  forty  degrees.  This  causes  the  intestines  to 
withdraw  into  the  upper  portions  of  the  peritoneal  cavity,  or  if  they  do  not 
take  this  position  by  their  own  weight,  the  object  may  be  accomplished  by 
pushing  the  intestines  upwards  by  means  of  a  large,  moist,  sterile,  gauze 
compress.  The  intestines  should  be  carefully  tamponed  away  from  the  seat 
of  the  operation,  as  thus  they  will  not  be  exposed  to  infection  during  the 
operation,  nor  to  the  irritating  influence  of  the  air. 

The  entire  operation  can  now  be  done  without  manipulating  anything  out- 
side of  the  pelvis,  and  this  portion  of  the  peritoneal  cavity  is  the  least  sensitive 
and  its  manipulation  is  accompanied  by  the  slightest  amount  of  shock.  This 
is  a  fact  of  very  great  importance,  and  if  borne  in  mind  the  patient's  suffer- 
ing may  be  reduced  greatly  and  her  chances  of  recovery  much  improved. 
The  further  steps  of  the  operation  will  depend  upon  the  extent  of  the  infec- 
tion and  upon  the  parts  involved,  as  well  as  upon  the  number  and  firmness  of 
adhesions. 

If  the  Fallopian  tubes  alone  are  concerned,  forming  sausage-shaped  bags 
of  pus,  the  operation  will  be  identical  with  that  described  for  the  removal  of 
ovarian  cysts.  The  broad  ligament  will  be  ligated  below  the  mass  and  a 
second  ligature  placed  around  the  Fallopian  tube  near  the  uterus  and  the 
mass  cut  away,  leaving  a  sufficient  amount  of  tissue  beyond  the  ligature  to 
prevent  slipping.  It  is  well  to  place  a  pair  of  forceps  upon  the  Fallopian  tube 
beyond  the  point  at  which  this  is  cut  away  in  order  to  prevent  any  leakage 
from  the  cut. 

Many  authorities  prefer  to  excise  a  conical  portion  of  the  uterus  together 
with  the  end  of  the  Fallopian  tube,  and  to  close  this  by  means  of  sutures. 
Theoretically  such  a  method  seems  preferable,  but  practically  there  is  no 
difference  between  the  two. 

If  the  adhesions  are  extensive  it  is  often  much  easier  to  place  two  pairs  of 
forceps  upon  the  Fallopian  tube  at  its  point  of  entrance  into  the  uterus.  The 
forceps  should  be  placed  parallel  to  each  other;  then  the  tube  cut  away 
between  these,  which  opens  the  space  between  the  upper  and  lower  fold  of 


626  SURGERY  OF  THE  FEMALE  PELVIS 

the  broad  ligament.  By  applying  forceps  successively  upon  the  broad  liga- 
ment from  within  outward,  and  cutting  between,  it  is  usually  possible  to 
enucleate  the  pus  tube  without  the  danger  of  rupturing  it.  In  many  cases 
the  uterus  itself  seems  so  thoroughly  infected  that  it  may  be  best  to  remove 
it  together  with  the  tubes  and  ovaries.  Then  the  operation  described  for  the 
removal  of  the  uterus  containing  fibroid  tumors  may  be  employed,  great  care 
being  taken,  of  course,  to  prevent  a  rupture  of  the  abscess.  It  is  in  such  cases 
that  the  method  of  splitting  the  uterus  longitudinall}'  is  often  of  especially 
great  value.  The  remaining  steps  are  the  same  as  those  which  have  been 
already  pointed  out. 

Here  again  it  is  particularly  important  to  exercise  care  in  inspecting  the 
surfaces  of  the  small  intestines  which  have  been  adherent  to  the  ovaries  or 
tubes,  or  to  the  infected  uterus,  as  in  loosening  these  adhesions  it  sometimes 
happens  that  a  loop  of  intestine  is  perforated,  and  unless  such  perforation  is 
carefully  closed  and  the  surface  covered  with  peritoneum  a  fecal  fistula  is 
apt  to  occur  and  the  intestinal  contents  may  cause  an  infection  of  the  perito- 
neum, giving  rise  to  a  septic  peritonitis  from  which  the  patient  may  die. 

After  all  of  the  diseased  tissue  has  been  removed  it  is  wise  to  cover  the 
abraded  surfaces,  as  far  as  possible,  with  portions  of  the  surrounding  healthy 
peritoneum.  If  this  cannot  be  done  the  sigmoid  flexure  should  be  brought 
down  and  placed  across  this  portion  of  the  pelvis,  and  if  there-  is  doubt  about 
this  remaining  in  position  it  is  well  to  fasten  it  by  means  of  a  few  catgut 
stitches.  The  omentum  should  also  be  brought  down  to  this  surface.  If  the 
operation  has  been  accomplished  without  causing  a  rupture  of  the  abscess  the 
surface  should  be  sponged  perfectly  dry,  the  gauze  tampons  placed  for  the 
protection  of  the  surrounding  intestines  should  be  removed,  and  it  is  well  to 
bring  the  omentum  down  from  the  small  intestines  so  that  these  do  not  come 
in  contact  with  the  field  of  operation,  because  of  the  danger  of  distribution 
of  infectious  material  bj^  peristaltic  motion. 

If  there  is  any  doubt  about  the  aseptic  state  of  the  field  of  operation  it 
is  always  best  to  apply  some  form  of  drainage.  We  have  found  a  curved  glass 
drainage  tube,  half  an  inch  in  diameter,  placed  within  a  strand  of  iodoform 
gauze  behind  the  stump  of  the  uterus  in  the  cul-de-sac  of  Douglas,  and  per- 
mitted to  protrude  through  the  lower  angle  of  the  wound,  most  satisfactory. 
This  tube  can  usually  be  removed  on  the  second  day,  and  the  gauze  surround- 
ing it  two  days  later,  permitting  the  abdominal  wound  to  close  perfectly  with- 
out danger  of  the  formation  of  ventral  hernia. 

If  there  has  been  a  severe  infection  it  maj^  be  necessary  to  leave  the  tube 
in  place  for  a  longer  period  of  time. 

The  abdominal  wound  is  closed  down  to  the  drainage  tube  in  the  usual 
manner.  In  many  cases  it  is  simpler  and  better  to  puncture  the  vault  of  the 
vagina  with  a  pair  of  blunt-pointed  scissors  or  forceps  and  drain  the  infected 
area  directly  into  the  vagina  by  means  of  gauze  or  cigarette  drains,  or  by 
combining  these  with  rubber  drainage  tubes.  In  some  very  extensive  cases 
we  have  combined  this  method  with  that  just  described,  draining  both  through 
the  vagina  and  through  the  abdominal  wound. 

These  points  then  are  of  marked  importance : 

1st.     Banking  away  of  the  non-infected  contents  of  the  abdominal  cavity. 

2d.     Manipulation  of  only  the  structures  contained  in  the  pelvis. 

3d.     Care  to  prevent  perforation  of  the  intestine. 

4th.  Covering  of  all  raw  surfaces  either  with  peritoneum  or  with  the 
sigmoid  flexure  or  omentum,  or  both. 

5th.  Drainage  in  cases  in  which  the  surgeon  is  not  positive  that  the 
field  is  aseptic,  preferably  into  the  vagina. 

After-treatment.     If  these  patients  bear  the  administration  of  small,  fre- 


SURGERY  OF  THE  FEMALE  PELVIS  627 

quently-repeated  draughts  of  liot  water  well,  such  should  be  given.  If  this 
causes  nausea  or  vomiting  it  is  best  simply  to  have  the  patient's  mouth  rinsed 
with  hot  or  cold  water  and  not  give  anything  by  mouth  for  two  days.  At 
the  end  of  such  time  beef-tea  or  one  of  the  various  concentrated  predigested 
foods  may  be  given  every  two  hours  in  small  doses.  After  two  days  these 
patients  usually  bear  hot  water  well.  Rectal  feeding  is  generally  somewhat 
dangerous  because  of  the  congestion  which  follows  an  exjtensive  operation 
in  the  pelvis.  The  alimentary  canal  should  be  perfectly  empty  before  the 
operation,  as  a  result  of  the  administration  of  two  ounces  of  castor  oil  on 
the  previous  day.  If  no  further  food  is  given  by  mouth  morphine  may  safely 
be  administered  hypodermatically  if  necessary,  to  quiet  the  pain.  Of  course, 
in  cases  which,  for  any  reason,  must  be  operated  during  the  acute  attack 
no  cathartic  should  be  given  before  the  operation,  for  fear  of  causing  the 
septic  material  to  be  carried  from  its  circumscribed  location  to  distant  por- 
tions of  the  abdominal  cavity  by  the  production  of  peristalsis  resulting  from 
the  cathartic. 

If  for  any  reason  it  seems  objectionable  to  perform  an  abdominal  sec- 
tion in  these  cases,  the  uterus,  ovaries  and  tubes  may  be  removed  by  the  vag- 
inal route,  to  be  described  later.  The  objection  to  this  route  lies  in  the  fact 
that  the  conditions  cannot  be  so  perfectly  determined  and  one  frequently 
removes  organs  which  might  be  saved  if  the  abdominal  operation  were  chosen. 
It  also  happens  frequently  that  a  diseased  vermiform  appendix  is  overlooked. 

In  the  criminal  classes  we  believe  this  operation  is  indicated  much  more 
commonly  than  among  other  patients,  because  re-infection  is  almost  certain 
to  occur  if  the  uterus  is  not  removed  together  with  the  other  infected  organs. 

In  all  of  these  patients  it  is  extremely  important  to  leave  at  least  a  por- 
tion of  one  ovary  so  long  as  the  patient  has  not  passed  the  menopause,  as 
if  both  ovaries  are  completely  removed  in  young  women  the  patient  is  likely 
to  suffer  from  severe  nervous  disturbances.  These  may  fortunately  be  avoided 
by  leaving  a  portion  of  one  ovary. 

TRANSPLANTATION    OF   THE    OVARIES 

In  many  of  these  cases  in  which  both  ovaries  have  been  removed  at  a 
previous  operation,  great  benefit  may  be  secured  by  transplanting  a  fairly 
healthy  ovary  hy  the  following  method:  It  is  best  to  select  for  a  source  an 
ovary  which  must  be  removed  because  of  prolapse  in  a  case  in  which  the 
fellow  ovary  is  quite  normal  and  in  which  it  seems  unlikely  that  any  opera- 
tion short  of  removal  would  result  in  the  relief  of  the  patient.  This  ovary 
may  be  preserved  in  sterile  normal  salt  solution  for  several  days  or  weeks 
and  may  then  be  transplanted,  but  it  is  probably-  better  to  make  the  trans- 
plantation directly  from  one  patient  to  the  other. 

Technique  of  operation.  An  incision  ten  cm.  long  is  made  over  the  mid- 
dle of  the  rectus  abdominis  muscle.  The  aponeurosis  is  split  and  also  the 
muscle.  Its  posterior  surface  is  separated  from  the  transversalis  fascia.  The 
ovary  is  laid  open  by  means  of  a  longitudinal  incision.  The  ovary  is  then 
placed  in  the  pocket  between  the  muscle  and  the  transversalis  fascia,  with 
the  raw  surface  caused  by  splitting  directed  toward  the  muscle.  It  is  held 
in  place  by  a  few  fine  catgut  sutures,  then  the  split  in  the  muscle  is  sutured, 
and  the  aponeurosis  and  skin  wounds  are  closed  and  an  ordinary  dressing 
applied.  If  the  uterus  has  not  been  removed  and  the  patient  is  young,  menstru- 
ation may  be  re-established  and  the  nervous  disturbances  due  to  the  artificial 
menopause  are  likely  to  disappear. 

It  is  of  course  important  to  choose  an  ovary  from  a  patient  who  is  free 


628  SURGERY  OF  THE  FEMALE  PELVIS 

from  syphilis  and  tuberculosis.     It  may  be  well  to  test  the  donor  with  one 
of  the  various  tests  for  tuberculosis  and  for  syphilis  in  order  to  be  quite  safe. 

CARCINOMA  OF  THE  UTERUS 

Abdominal  vs.  vaginal  hysterectomy.  During  the  past  few  years  there  has 
been  much  difference  of  opinion  regarding  the  advisability  of  treating  the 
various  surgical  diseases  of  the  pelvic  cavity  through  an  abdominal  incision,  or 
through  a  vaginal  incision ;  the  general  surgeon,  as  a  rule,  being  more  familiar 
with  the  abdominal  route  than  with  the  vaginal,  has  usually  supported  the 
former,  w^hile  the  gynecologist  has  more  commonly  advised  the  vaginal  route 
for  the  relief  of  all  conditions  that  could  be  accomplished  through  a  vaginal 
incision.  The  abdominal  route  has  undoubtedly  the  advantage  of  enabling  the 
surgeon  to  expose  the  pelvic  cavity  freely,  especially  since  these  operations  are 
performed  with  the  patient  in  the  Trendelenburg  position,  by  means  of  which 
the  intestines  can  easily  be  removed  from  the  pelvis,  leaving  only  the  uterus 
and  adnexae,  the  bladder  and  the  rectum  in  this  cavity.  This  route  also  per- 
mits the  surgeon  to  examine  the  appendix,  for  disease  frequently  the  con- 
comitant of  other  pelvic  troubles ;  it  also  enables  him  to  examine  the  gall 
bladder  and  to  dispose  of  adhesions  between  the  omentum  or  the  intestines 
and  the  pelvic  organs.  The  vaginal  route  has  the  advantage  of  being  safer  in 
the  hands  of  a  surgeon  who  is  familiar  with  this  class  of  operations,  the  mor- 
tality in  all  forms  of  operations  performed  by  this  route  being  exceedingly  low. 

There  is  the  further  advantage  in  the  fact  that  no  external  scar  is  produced 
by  this  avenue  which  is  of  importance  to  some  patients  who  are  exceedingly 
sensitive.  In  order  to  overcome  this  objection  Pfannenstiel  introduced  the 
transverse  incision  for  abdominal  section,  made  in  the  area  covered  by  the 
pubic  hair  which  will  later  hide  the  scar  completely. 

VAGINAL  HYSTERECTOMY 

This  operation  is  indicated  in  carcinoma  of  the  uterus  so  long  as  this  organ 
is  movable  and  there  is  no  positive  evidence  of  the  invasion  of  any  of  the  sur- 
rounding tissues,  and  no  infection  of  the  inguinal  lymphatic  glands. 

Cautery  for  carcinoma  of  the  cervix.  If  the  organ  is  no  longer  movable 
the  patient  has  lived  longer  and  more  comfortably,  in  our  experience,  if, 
instead  of  removing  the  uterus  we  protect  the  vaginal  walls  and  thoroughly 
cauterize  the  entire  uterine  cavity  by  introducing  cautery  irons  heated  to 
red  heat.  The  most  convenient  form  of  cautery  iron  for  this  purpose,  according 
to  our  observation,  is  the  ordinary  soldering  iron  heated  in  a  tinner's  heater, 
in  a  coal  fire  or  in  the  flame  of  a  gas  stove.  A  number  of  these  irons  are  placed 
in  the  flame  and  are  introduced  into  the  cavity  of  the  uterus  successively  until 
the  entire  cavity  has  become  lined  with  an  eschar.  An  iodoform  gauze  pad 
covered  with  glycerine  is  then  inserted  and  a  retention  catheter  introduced 
into  the  bladder.  After  the  eschar  separates  the  connective  tissue  which  forms 
during  the  process  of  healing  contracts  the  organ  and  is  likely  to  retard  the 
progress  of  the  disease.  Many  of  these  patients  improve  so  much  that  the 
surgeon  is  prone  to  doubt  his  diagnosis,  and  one  of  our  cases,  which  seemed 
at  the  time  entirely  inoperable  and  hopeless,  lived  for  a  period  of  nineteen 
years  and  died  of  an  intercurrent  disease  without  having  had  a  recurrence  of 
the  carcinoma.  A  number  of  other  cases  have  lived  from  three  to  ten  years. 
Of  course,  this  is  not  the  rule.  Most  patients  have  a  recurrence  within  one 
or  two  years,  to  which  they  succumb. 

Importance  of  early  diagnosis.  The  most  important  point  regarding  the 
treatment  of  carcinoma  of  the  uterus,  however,  is  early  diagnosis  and  imme- 


SURGERY  OF  THE  FEMALE  PELYIS 


629 


diate  treatment.  In  order  to  make  an  early  diagnosis  vre  believe  it  is  import- 
ant that  the  surgeon  should  make  a  careful  examination  in  every  case  in  which 
there  is  the  slightest  suspicion  of  malignancy.  This  is  true  especially  at  about 
the  period  of  the  menopause,  or  after  the  end  of  this.     In  almost  every  case 


Vaginal  Hysterectomy. 

The  vaginal  orifice  is  held  open  by  means  of  specula  (e)  (d).  The  cervix  (a)  is  loosened 
from  its  vaginal  attachment  by  an  elliptical  incision.  The  uterine  arteries  are  picked  up 
with  a  cat-gut  suture  (b)  and  tied.  Sutures  are  inserted  on  either  side  (e)  for  the  closure 
of  the  wound,  but  left  untied  until  the  uterus  has  been  removed. 


which  has  come  under  our  care  for  treatment,  there  has  been  a  history  of 
uterine  hemorrhages  more  or  less  extensive.  If  these  hemorrhages  occur  in  a 
patient  fifty  years  of  age,  or  over,  the  physician  should  recognize  the  gravity 
of  this  symptom.    If  he  temporizes  without  having  satisfied  himself  positively 


630  SURGERY  OF  THE  FEMALE  PELVIS 

regarding  the  diagnosis,  the  chances  are  that  by  the  time  the  diagnosis  is  made 
the  case  has  passed  beyond  the  stage  at  which  surgical  intervention  could  result 
in  permanent  benefit. 

Dangers  of  diagnostic  sections  and  curettement.  If  the  growth  begins  in 
the  cervical  portion  of  the  uterus,  which  is  its  most  common  origin,  then  it  can 
be  at  once  discovered  upon  a  digital  examination  or  with  the  speculum.  In 
case  the  tissues  appear  suspicious,  with  this  history  and  at  this  age,  we  believe 
that  a  hysterectomy  should  be  performed  at  once.  In  many  cases  in  which 
portions  of  the  malignant  growth  have  been  removed  for  microscopical  exam- 
ination our  experience  has  been  that  this  simple  procedure  has  resulted  in  the 
stimulation  of  the  growth  to  such  an  extent  that  even  in  very  recent  examples 
there  has  been  no  permanent  cure  after  this  method  of  diagnosis  has  been 
employed.  AVe  believe  that  the  removal  of  a  portion  of  tissue  for  microscopical 
examination  prior  to  operation  should  be  most  strongly  condemned.  The 
same  is  true  if  hemorrhages  occur  in  patients  after  the  menopause,  in  whom 
neither  cervical  carcinoma  nor  fibroid  of  the  uterus  can  be  diagnosed  by  phys- 
ical examination.  In  these  it  has  been  the  practice  to  do  a  curettement  of 
the  lining  of  the  uterine  cavity  and  make  a  microscopical  examination  of  the 
portions  curetted  away.  Here,  again,  the  danger  of  infection  with  carcinoma 
is  so  great  that  we  believe  the  practice  should  be  absolutely  abandoned. 

Operative  technique.  The  danger  of  infection  with  carcinoma  during  the 
operation  should  be  thoroughly  borne  in  mind,  because  it  is  not  necessary  dur- 
ing the  operation  to  wound  any  portion  which  has  been  infected.  If  the  mass 
projecting  from  the  cervix  has  a  cauliflower  appearance  it  should  be  removed 
by  means  of  a  cautery  before  the  operation  is  begun,  because  in  this  way  all 
of  the  surfaces  through  which  the  incision  is  to  be  made  are  destroyed  by  the 
heat,  and  consequently  an  infection  from  them  is  not  possible.  After  the  cervix 
has  been  cleansed  by  means  of  the  cautery,  if  the  carcinoma  be  cervical  in 
character,  a  pair  of  volsellum  forceps  may  be  inserted  a  sufficient  distance 
away  from  the  carcinomatous  tissues  to  insure  that  they  do  not  cause  implanta- 
tion into  the  latter.  The  vaginal  mucous  membrane  is  then  severed  circularly 
around  the  entire  cervix,  at  a  distance  of  at  least  two  centimeters  from  the 
margin  of  the  diseased  tissue,  by  means  of  a  Pacquelin  or  an  electric  cautery. 
AVe  believe  that  some  of  the  recurrences  in  our  cases  have  been  due  to  a  neglect 
of  this  plan.  Since  we  adopted  the  plan  of  severing  the  vaginal  mucous  mem- 
brane with  the  cautery  a  number  of  years  ago  we  have  had  no  recurrences  in 
the  vagina,  while  formerly  this  was  a  common  location  for  recurrence. 

The  uterus  is  then  drawn  downward  and  the  dissection  carried  on  in  front 
and  behind  by  means  of  the  cautery  until  the  peritoneal  layer  is  approached, 
care  being  taken  throughout  this  part  of  the  operation  to  avoid  injuring  the 
bladder  in  front  and  the  rectum  behind.  The  location  of  the  bladder  may  be 
determined  by  occasionally  inserting  a  steel  sound  through  the  urethra 
throughout  the  progress  of  the  operation.  After  the  dissection  has  been  car- 
ried to  this  point  by  means  of  the  cautery,  the  peritoneal  cavity  is  opened 
anteriorly  by  blunt  dissection  with  the  finger,  and  then  it  is  opened  posteriorly 
in  the  same  manner  and  a  piece  of  sterilized  gauze  carried  behind  the  cervix 
into  the  cul-de-sac  of  Douglas  in  order  to  prevent  the  soiling  of  the  latter 
cavity  from  the  cervix.  The  fundus  of  the  uterus  is  then  brought  to  the  an- 
terior opening  in  the  peritoneal  cavity,  or  through  the  posterior  opening, 
according  to  the  direction  in  which  this  can  be  accomplished  most  easily.  If 
the  fundus  is  brought  down  posteriorly,  then  a  piece  of  sterile  gauze  should  be 
inserted  anteriorly  to  protect  the  peritoneal  cavity  against  soiling. 

The  manner  in  which  the  uterus  can  be  brought  down  most  convenientlj^ 
is  by  means  of  the  cat's-paw  retractors,  as  indicated  in  the  plate.  The  ovary 
and  tube  on  one  side  are  then  brought  forward  into  the  wound  by  means  of 


SURGERY  OF  THE  FEMALE  PELVIS 


631 


forceps  placed  upon  the  broad  ligament,  or  by  digital  manipulation.  Then  a 
pair  of  heavy,  long- jawed  compression  forceps  is  applied  to  the  broad  ligament 
beyond  the  ovary  and  tube  from  above  downwards,  in  order  to  avoid  the 
ureters.    These  forceps  should  be  so  constructed  that  it  is  impossible  for  the 


Vaginal  Hysterectomy. 

The  orifice  is  held  open  as  in  the  previous  plate.  The  peritoneal  cavity  has  been  opened 
in  front  and  behind  the  cervix  and  the  uterus  has  been  brought  down  and  inverted  by  means 
of  traction  with  the  cat's-paw  retractor  (c). 

tissue  to  slip  out  of  their  grasp.  The  broad  ligament  is  then  cut  along  these 
forceps  and  a  second  pair  of  the  same  kind  is  applied  to  the  remaining  portion 
of  the  lateral  pedicle  containing  the  remainder  of  the  broad  ligament,  together 
with  the  uterine  artery.  The  remainder  of  the  pedicle  is  then  severed  and  the 
uterus  is  attached  now  only  upon  one  side.    It  is  then  an  easy  matter  to  bring 


632 


SURGERY  OF  THE  FEMALE  PELVIS 


out  the  other  ovary  and  tube  and  to  clamp  the  pedicle  beyond  these  in  the 
manner  which  has  just  been  described.  The  uterus  is  then  entirely  cut  away 
A  strand  of  iodoform  gauze  is  placed  over  the  ends  of  these  forceps  in  order  to 
prevent  them  from  doing  injury  by  coming  in  contact  with  the  intestines  in  the 


Vaginal  Hysterectomy. 


f>,o  ,The^  uterus  has  been  removed;  the  left  broad  ligament  is  still  held  with  clamp  foreeDS 
the  ligature  being  in  place,  but  not  tied.  The  clamp  forceps  have  been  removed  from  the 
right  Droad  ligament  (b)  and  the  ligature  has  been  tied.  A  piecl  of  ioSrm%auz^  has 
been  sutured  to  the  stumps  of  the  broad  ligaments  with  two  cat-^t  sutures  (c) 

peritoneal  cavity   and  then  the  points  of  the  forceps  are  pushed  up  into  the 
peritoneal  cavity  beyond  the  vaginal  wound.     A  further  tampon  is  placed  in 
^wr^?-""!  f  *^'  ^^^^^\^^d  tlie  outlet  of  the  vagina  is  tamponed  with  a 
piece  of  iodoform  gauze,  thoroughly  saturated  with  vaseline,  in  order  to  pre 
vent  the  soiling  of  the  deeper  tampons  from  without.     The    ntroduction  of  a 


SURGERY  OF  THE  FEMALE  RELAYS  633 

retention  catheter  and  the  application  of  the  external  dressing  completes  the 
operation. 

It  has  seemed  to  us  that  there  exists  a  distinct  advantage  in  using  the 
clamps  for  the  purpose  of  hemostasis  in  preference  to  a  ligature,  because  the 
line  of  incision  through  the  pedicle,  which  might  be  a  favorable  field  for  infec- 
tion with  carcinoma,  is  thus  eliminated  on  account  of  the  sloughing  which 
takes  place  in  the  portion  contained  in  the  bite  of  the  forceps. 

After-care.  The  forceps  are  left  unmolested  for  twenty-four  hours  or 
thirty-six  hours,  when  they  are  loosened  and  left  in  place  so  that  the  portion 
contained  in  the  bite  of  the  forceps  may  spontaneously  retract  from  the  latter. 
Several  hours  later  the  forceps  can  be  withdrawn  without  giving  the  slightest 
amount  of  pain  to  the  patient,  while  if  they  are  withdrawn  at  once  upon  being 
loosened  the  act  is  usually  accompanied  by  a  considerable  amount  of  pain,  and 
occasionally  hemorrhage.  The  most  superficial  tampon  is  removed  at  the  time 
of  removing  the  forceps  and  fresh  vaseline  is  applied  to  the  parts.  The  deeper 
tampons  are  removed  from  the  fifth  to  the  eighth  day,  as  they  become 
loosened.  About  the  tenth  day  the  speculum  is  introduced  and  sloughs  which 
have  become  loosened  by  this  time  are  removed  by  means  of  dressing  forceps. 
After  the  last  piece  of  gauze  has  been  removed  the  patient  is  given  warm 
douches  of  some  mild  antiseptic  character,  from  three  to  six  times  a  day,  care 
being  taken  to  have  the  fountain  syringe  very  slightly  elevated,  so  that  it  is  not 
possible  for  the  stream  to  iiijure  the  adhesions  which  have  formed  in  the  upper 
portion  of  the  wound.  These  douches  are  a  source  of  comfort  to  the  patient 
and  are  perfectly  harmless  if  given  in  this  manner.  The  retention  catheter  is 
left  in  place  until  all  of  the  gauze  tampons  have  been  removed,  unless  it  gives 
rise  to  discomfort,  in  which  case  it  may  be  extracted  sooner,  and  the  urine 
withdrawn  by  means  of  catheterization.  If  the  catheter  is  left  in  place  too 
long  it  may  become  filled  with  phosphatic  concretions,  unless  a  few  drops  of  a 
dilute  mineral  acid  be  given  in  a  considerable  quantity  of  water  three  to  six 
times  daily. 

A  very  comfortable  external  dressing  consists  of  pads  saturated  with  one 
part  of  alcohol  and  two  parts  of  hot  water,  and  covered  with  a  large  piece  of 
dry  cotton  held  in  place  by  means  of  a  T-bandage.  Aside  from  this  the  after- 
treatment  is  the  same  as  in  any  ordinary  abdominal  section. 

Radiotherapy.  The  treatment  of  cancer  of  the  uterus  by  radio-active  sub- 
stances is  indicated  in  inoperable  and  recurrent  cancers,  as  well  as  operable 
ones,  and  is  either  palliative,  curative  or  prophylactic.  It  is  palliative  if  the 
rays  cannot  reach  all  the  cancer  cells  or  cancer  cell-nests.  The  rays  influence 
only  the  cells  that  are  within  their  reach.  Cancer  cells  not  within  the  area  of 
the  activity  of  the  rays  will  of  course  continue  to  proliferate,  which  prolifera- 
tion after  a  certain  time  reaches  such  a  proportion  as  to  again  jeopardize  the 
patient's  life.  Radio-active  substances  will  cure  a  cancer  if  they  can  destroy 
all,  absolutely  all.  cancer  cells.  The  rays  are  used  as  a  prophylactic  after  ex- 
tended, radical  removals  of  cancers  to  destroy  cancer  cells  or  cancer  cell-nests 
which  have  been  left  behind  during  the  operation.  "With  our  present-day 
knowledge  of  cancer  disease,  as  well  as  of  the  action  of  the  radio-active  sub- 
stances, it  would  be  folly  to  treat  cancer  solely  by  the  latter.  On  the  contrary 
the  patient  must  receive  the  best  surgical  treatment  if  the  case  is  operable, 
and  this  must  be  augmented  by  radium  and  X-ray  applications.  Radiotherapy, 
therefore,  is  an  adjunct  of  surgery-  and  the  best  results  are  obtained  when  it 
is   combined   with   proper   surgical   treatment. 

The  biologic  action  of  mesothorium,  radium  and  the  Rontgen  rays  is  identi- 
cal. The  rays  either  stimulate  the  embryologic  cell  to  mature  into  adult, 
differentiated  cells,  or  they  destroy  the  cancer  cells  by  producing  a  gigantism 


634 


SURGERY  OF  THE  FEilALE  PELVIS 


followed  by  a  karrolysis  and  death  of  the  celL    At  the  same  time  the  eoime.: 
tive  tissue  increases  penetrating  the  cancer  masses,  which  process  is  further 
accompanied  bv  a  marked  leucocrtic  cell  infiltration. 

The  therapeutic  action  of  radium  and  mesothorium  depends,  1st,  on  the 
amount  and  compactness  of  the  substance  used:  2nd,  on  the  duration  and  *r^zn^ 


VaGI^.'AI.    HYSrE2.SCT01IT. 


The  operation  completed.    The  orifice  L 
raolt  (a)  closed  by  tying  the  sutures.    The 


■i  (d). 
olaee. 


The  vaginal 


concentration  of  the  treatment  and  3rd,  on  the  filtering  employed.  The  amount 
of  radium  or  mesothorium  necessary  for  a  successful  therapy  should  be  at 
least  25  mg.  radium  element.  The  mean  amount  recommended  by  most  investi- 
gators is  placed  at  50  mg.  radium  element.  It  m  important  to  determine  the 
milligrams  of  radium  element  contained  in  the  radium  applicator.  Fifty  milli- 
grams of  radium  bromid  contain  26.8  mg.  radium  element:  50  me.  radium 


SURGERY  OF  THE  FEMALE  PELVIS  635 

chlorid  contain  38.95  mg.  radium  element ;  50  mg.  radium  sulphate  contain 
35.1  mg.  radium  element ;  and  50  mg.  radium  carbonate  equal  39.5  mg.  radium 
element.  Radium  sulphate  is  insoluble  in  water  and  body  fluids  and  hence 
best  suited  for  our  purposes.  If  a  radium  container  should  accidentally  break 
or  deteriorate  while  inserted  in  a  patient  the  sulphate  will  not  dissolve  and 
therefore  a  loss  of  the  precious  metal  is  prevented. 


^r.  I'j:] 


'     V)     v,*^        '"  .  ';'>,.VW' 


I 


^  .  -I,  / 


7      '    '' 


^^€i3'\^'   '<  •*   '\^!''' 


ay  :^'  .f 


/Vi 


:^oJ  VAr\- 


e 


^i'^'Mrf'- 


It    '^ 


dr. 


■b 


t'l    J 


Section  taken  from  crater  in  ceivix  uteri  before  ladium  was  applied.  Mrs.  E.,  Augustana 
Hospital,  Number  40202.     June  4,  1914. 

Ocular  10,  eyepiece  4  mm.,  tube  length  160  mm. 

A. — Typical  medullary  type  of  cancer  arising  probably  at  the  .iunction  of  vaginal  and 
cervical  mucosae.  Homogeneous  areas  of  large  cancer  cells  are  seen,  many  exhibit  mytotic 
Igures  and  others  evidence  of  onward  growth. 

B. — Individual  large  cancer  cells  are  also  found  in  the  lymph  spaces  of  the  originally 
parenchymatous  tissues. 

C— There  is  no  new  fibrous  tissue  but  instead  it  is  seen  that  the  normal  tissues  have 
been  separated  and  displaced  by  the  atypical  new  growth  of  cells. 

The  radio-activity  of  mesothorium  is  expressed  in  the  milligrams  of  an 
amount  of  radium  bromid  of  the  same  radio-activity.  Hence  50  mg.  of  meso- 
thorium does  not  mean  that  the  quantity  of  the  substance  weighs  50  mg.  but 
that  it  possesses  the  same  radio- activity  as  50  mg.  radium  bromid.  The  action 
of  50  milligrams  of  radium  element  for  ten  hours,  i.e.,  500  milligram  hours  or 
milligramage,  differs  from  that  of  five  mg.  radium  element  applied  for  one 
hundred  hours,  i.e.,  also  500  milligram  hours.    The  intensity  of  the  radio-activ- 


636  SURGERY  OF  THE  FEMALE  PELVIS 

ity  increases  in  an  inverse  ratio  to  the  amount  used  and  its  compactness  within 
the  applicator. 

The  duration  of  the  radium  treatment  depends  on  the  results  obtained,  i.e., 
the  local  disappearance  of  the  cancer. 

A  crowding  of  the  milligramage  into  the  shortest  possible  time  seems  to 
give  better  results  than  when  long  intervals  are  had  between  treatments. 
The  average  amount  which  we  find  necessary  in  a  case  seems  to  be  3,000  to 
6,000  milligrams  hours,  and  we  always  endeavor  to  apply  this  amount  within 
a  time  period  of  about  two  weeks.  An  exception  is  made  in  patients  in  whom 
the  side-actions  are  severe.  Under  these  conditions  we  wait  with  the  next 
application  until  they  have  disappeared.     As  the   action   of  radium  on  the 


'•  i 

Same  tissue  after  4350  milligram  hours  of  radium  element  has  been  used. 

Ocular  10,  eyepiece  4  mm.,  tube  length  160  mm. 

Al- — Aiv  area  of  cancer  cells  similar  to  those  in  first  section,  except  that  vacuoles  and 
numerous  small  granules  in  protoplasm  are  seen  in  some  of  the  cells.  Many  of  the  nuclei 
are  broken  up  in  two,  three  and  more  portions. 

B. —  A  giant  cell. 

C. — Individual  cancer  cells  in  lymph  spaces  with  marked  granulation  of  protoplasm. 

D. — Parenchyma  containing  many  new  fibroblasts. 

tissues  is  latent,  the  latency  being  from  three  to  six  weeks,  we  postpone  any 
further  treatment  until  after  the  lapse  of  this  period.  If,  however,  the  cancer 
should  show  a  renewed  activity  then  treatments  are  immediately  reinstituted. 
Only  the  hardest  rays  must  be  used  in  cancer  work  as  only  these  are 
penetrating.  This  is  accomplished  by  filtering  the  rays  to  exclude  all  of  the 
a  and  6  rays.  The  filters  commonly  used  are  made  of  silver,  lead,  platinum, 
aluminum  or  brass.  A  1.5  mm.  silver  filter,  a  0.5  mm.  platinum  filter,  a  3  mm. 
lead  filter,  a  3  mm.  aluminum  filter  or  a  1.0  mm.  or  1.5  mm.  brass  filter  will 
arrest  all  of  the  a  and  6  rays.  The  extent  of  the  penetrative  power  of  the 
therapeutic  action  of  the  y  rays  of  radium  and  mesothorium  has  been  deter- 
mined by  Bumm  and  his  associates  and  is  3  to  3.5  cm.     Hence  an  area  of  a 


SUEGEKY  OF  THE  FE^IALE  PELVIS 


637 


diameter  of  6  to  7  cm.  is  subjected  to  the  action  of  the  y  rays.  Secondary  rays 
identical  with  soft  6  rays  in  their  physical  and  biological  action  are  pro'duced 
in  the  metal  filters  by  the  radium.  These  must  be  arrested,  which  may  be  done 
by  surrounding  the  filter  with  pure  para  rubber  of  a  thickness  of  2  mm.,  free 
of  any  inorganic  substances.  Several  thicknesses  of  gauze,  say  sixteen  to 
twenty-four  layers,  may  serve  the  same  purpose. 


SC'IS 


f''°:,'l^/'^\-^X 


i&!?&itl*  ■ 


Same  uterus  after  9250  milligram  hours  radium  element  were  applied. 

Ocular  10,  eyepiece  16  mm.,  tube  length  160  mm. 

A. — Blood  vessel  surrounded  by  mixed  muscle  and  fibrous  tissue  (c). 

B. — Large  horseshoe  shaped  area  of  cancer  cells  undergoing  very  marked  retrograde 
processes  as  shown  best  by  high  power  illustration  following. 

D. — Several  isolated  degenerated  and  necrotic  cancer  cells  surrounded  by  fibrous  tissuB 
and  lymphocytes. 

E. — Large  dilated  blood  vessels. 

F. — The  remaining  tissue  consists  mainly  of  1,  lymphocytes;  2,  fibroblasts  and  fibrous 
tissue;  3,  endothelial  cells;  4,  neutrophiles  and  5,  new  capillaries  and  lymph  vessels. 

Those  portions  of  the  vagina  which  are  normal  should  not  be  subjected  to 
the  action  of  radium.  A  latent  hyaline  degeneration  of  healthy  tissue  might 
lead  to  fistula  formation,  especially  of  the  bladder  and  rectum.  This  may 
be  prevented  by  protecting  the  vaginal  walls  by  additional  lead  plates  wrapped 
in  gauze,  which  at  the  same  time  serve  as  a  packing  to  retain  the  radium  appli- 
cator in  its  place. 

Distantly  located  cancer  metastases  and  tumors  are  treated  with  the  X- 


638  SURGERY  OF  THE  FEMALE  PELVIS 

rays.  The  success  of  their  action  depends  on  the  fact  that  a  sufficient  radio- 
intensity  must  be  attained  in  the  cancer  tissue.  To  obtain  500  x  in  a  depth 
of  10  cm.  3500  x  must  be  applied  to  the  body  surface.  Severe  injuries  of  the 
tissues  are  avoided  by  using  verj-  hard,  penetrating  and  filtered  rays  and 
many  portals  of  entrance.     We  use  a  water  cooled  tube  of  a  hardness  of  10 


•  "^ 

] 

*'''  .a 

r-v   •••''  '^-■ 

no  i^<': 

^':  v«;i- 

^ 

%"(?  ^      ..  •' 

.         :                                                     ''             /     > 

#^^^^ 

r-v 

•'                   „        -i             -.       ,                                      ^ 

tM^^S 

«tf  '           ,,  :,   J 

i7     ,     '                     1 

.1  =t/9   *fm-^   4'  £'t^ 

tl- 

e.       ^^r      1       H'^'if 

"-^        '^      *.               •  /®       ""^ 

6                            ' 

t 

ft 

^^-^^^c  <■.'«■    '-^^     "-••    ■  ^- 

■■■<        ? 

V^--.^'  ■•■,      i^ 

»       "■■'                                                       i»^               :■    ■               ■'" 

'-  ■           ■  ■  . .      '  ' ■ 

;;,.*^,  '*■                                    ; 

9                 ;,—          1          ^. 

'■*    '"       '' 

j:.r^_ 

or  g^ 

Hiy^li  power  magnification  of  the  area  marked  in   preceding  illustration. 

A. — Cells  with  a  comparatively  sharp  outline  containing  many  small  granules  in  the 
protoplasm. 

B. — A  cell  with  a  very  hazy  outline  and  a  horseshoe  shaped  nucleus  and  devoid  of  a 
nucleolus. 

C. — Cells,  also  with  a  hazy  outline,  in  which  the  protoplasm  is  almost  entirely  displaced 
by  vacuoles.     The  nuclei  are  broken  up  in  fragments. 

D. — A  cell  with  a  barely  visible  outline.  The  protoplasm  contained  many  large  and 
small  granules. 

E.— Fragments  of  nuclei  with  no  cell  outline  whatever.  There  are  no  cancer  cells  seen 
in  the  surrounding  tissue.  The  latter  consists  chiefly  of  lymphocytes,  fibre  cells  and  neutro- 
philes. 

to  13.5  Wehnelt,  and  control  the  constancy  of  the  tube  by  a  Ileinz  Bauer  quali- 
meter.  If  3  milliamperes  of  current  are  sent  into  such  a  tube  40  x  can  be 
applied  to  a  given  field  in  about  forty-five  minutes.  If  five  to  six  milliam- 
peres are  used  four  erythem  doses,  i.e.,  40  x  are  readily  reached  within  fifteen 
to  twenty  minutes. 


SURGERY  OF  THE  FEMALE  PELVIS  639 

Of  course  to  be  correct  the  amount  of  rays  given  is  always  determined  by  a 
Holzknecht  radiometer.  Forty  x  of  filtered  rays  is  the  largest  amount  that  may 
be  applied  to  a  single  field  every  three  weeks  without  causing  X-ray  injuries  as 
dermatitis,  burns,  etc.,  to  the  skin.  Such  a  field  measures  four  square  centi- 
meters. Twenty  to  thirty  such  fields  may  be  used  in  a  given  instance  and  the 
total  amount  applied  each  three  weeks  should  be  from  800  to  1,200  x.  These 
seances  are  repeated  until  such  time  as  the  metastases  and  other  tissue  indura- 
tions have  permanently  disappeared.  If  there  is  the  slightest  suspicion  of  re- 
currence the  applications  must  be  renewed. 

The  immediate  or  primary  results  of  radium  and  X-ray  treatment  of  inop- 
erable and  recurrent  cancers,  after  about  2,000  milligram  hours  of  radium 
element  have  been  given,  are  an  arrest  of  hemorrhage,  a  cessation  of  the  cancer- 
ous odor,  a  change  of  the  pyorrhea  to  a  serous  watery  discharge  and  an  ameli- 
oration or  subsidance  of  pain,  loss  of  cachexia  and  a  gain  in  weight  and 
strength.  An  inoperable,  walled-in  cancerous  uterus  often  becomes  movable, 
sometimes  within  three  weeks  and  can  then  be  plainly  outlined  by  bimanual 
palpation.  A  radical  pan-hysterectomy  may  now  be  performed.  Locally  the 
necrotic  cancer  debris  becomes  detached  and  the  crater  is  lined  with  healthy 
appearing  granulations.  These  changes  in  symptoms  and  signs  undoubtedly 
coincide  with  the  changes  in  the  microscopic  pictures.  The  side-actions  of 
radium  treatment  are  nausea  and  vomiting,  diarrhea,  rectal  and  vesical  tenes- 
mus, a  burning  in  the  pelvis,  a  general  malaise  and,  in  some  cases,  a  high  and 
continued  temperature.  However,  these  symptoms  are  only  transitory  and 
should  never  occasion  alarm. 

The  late  results  of  radium  treatment  in  inoperable  and  recurrent  uterine 
cancers  are  unfortunately  very  discouraging.  After  the  "clinical"  cure  has 
existed  for  a  short  period  (three  to  six  months)  a  recurrence  of  the  cancer 
is  seen.  The  latter  has  lost  the  radio-sensibility,  it  is  "radium  fast."  The 
action  of  the  X-rays  applied  in  combination  with  the  radium  rays  is  identical 
with  the  latter.  The  patient,  also,  after  a  period  of  apparent  symptomatic 
cure  loses  her  rontgen-sensibility  and  further  applications  are  negatized.  Out 
of  nineteen  cases  of  inoperable  and  recurrent  cancers  we  possess  only  three 
which  so  far  have  not  recurred.  Radiotherapj^,  therefore,  is  usually  only  a 
palliative  measure  in  inoperable  cancers,  but  as  such  it  ranks  in  first  place. 

The  use  of  radiotherapy  after  extended  radical  abdominal  pan-hysterecto- 
mies for  carcinoma  uteri  is  undertaken  as  a  prophylactic  treatment  to  destroy 
cancer  cells,  or  tissue,  that  have  been  left  behind  and  to  prevent  recurrences. 
The  stumps  of  the  broad  ligament  are  usually  covered  with  necrotic  tissue 
which  gives  rise  to  a  penetrating  odor,  purulent  discharge  and  continued  tem- 
perature, irregular  pulse  and  retarded  convalescence.  The  radium  changes 
these  conditions  as  if  by  magic.  Healthy  granulations  replace  the  necrotic 
masses,  the  putrid,  purulent  discharge  is  changed  to  an  aqueous,  scanty  secre- 
tion, convalescence  immediately  becomes  normal.  Our  cases  are  too  recent  to 
permit  expressions  as  to  the  remote  results  of  the  prophylactic  use  of  rays  after 
extirpations.  All  our  cases  so  far  have  remained  well.  Kronig  rayed  twenty 
cases  after  radical  operations.  Seventeen  of  these  cases  which  were  treated 
one  and  one  half  to  three  years  ago  are  at  present  still  free  of  any  recurrences, 
while  cases  not  rayed  have  shown  60  per  cent,  recurrences  within  the  first 
year  following  the  operation. 

Prognosis.  The  prognosis  depends  upon  the  extent  of  the  invasion  of  the 
tissues  by  the  disease.  If  the  operation  is  performed  early  and  the  cautery 
used  in  severing  the  tissues,  and  the  remaining  steps  followed,  as  has  been 
indicated,  the  prognosis  is  fairly  good.  In  advanced  cases  of  carcinoma  the 
prognosis  is  bad. 


640  SURGERY  OF  THE  FEMALE  PELVIS 

COMBINED  VAGINAL  AND  ABDOMINAL  HYSTERECTOMY 

In  more  advanced  cases  the  combined  vaginal  and  abdominal  operation  has 
been  advised  by  many  authorities,  because  it  has  been  claimed,  especially  by 
Ries,  that  it  will  be  possible  to  remove  the  infected  glands  by  following  this 
method,  and  thus  to  prevent  recurrence  in  cases  in  which  the  removal  by  the 
vaginal  route  would  be  useless.  It  is  doubtful  whether  it  is  possible  to  remove 
all  of  the  infected  glands  in  any  case  in  which  the  lymph  nodes  at  some  dis- 
tance from  the  uterus  have  become  infected  with  carcinoma,  but  there  is  no 
doubt  that  this  operation  is  more  thorough  than  the  one  just  previously 
described  and  the  increased  danger  is  so  slight  that  the  operation  is  at  least 
justifiable  in  any  case  in  which  it  seems  plain  that  the  disease  cannot  be 
removed  entirely  by  the  vaginal  route,  and  is  not  sufficiently  advanced  to 
absolutely  contraindicate  an  attempt  at  a  removal. 

In  our  own  experience  these  patients  have,  however,  lived  longer  as  a  rule, 
when  we  have  treated  the  growth  with  very  extensive  destruction  with  the 
actual  cautery,  which  seemed  to  be  more  far-reaching  in  its  effect  than  removal 
by  the  most  careful  dissection. 

In  making  the  combined  operation  it  is  important  to  remove  all  of  the 
lymph  nodes  in  the  broad  ligaments  and  along  the  iliac  vessels.  This  dissec- 
tion is  best  accomplished  by  splitting  the  peritoneum  and  then  dissecting  away 
the  fat  and  the  lymph  nodes  with  a  gauze  pad,  according  to  the  method 
described  in  connection  with  the  removal  of  fat  and  lymphatics  of  the  axillary 
space  for  carcinoma  of  the  breast. 

All  of  the  raw  surfaces  are  then  covered  with  peritoneum  and  a  gauze  or 
cigarette  drain  is  passed  down  into  the  vagina. 

It  is  best  to  begin  the  combined  operation  from  below,  burning  away  the 
vaginal  attachment  precisely  as  described  in  the  previous  operation  and  grasp- 
ing the  broad  ligaments  from  below  and  clamping  the  lower  portion  of  the 
broad  ligament  on  each  side  with  strong  hemostatic  clamps  and  burning  be- 
tween these  and  the  cervix  with  the  actual  cauter^^  This  space  is  then 
thoroughly  tamponed  with  gauze  and  then  the  patient  is  placed  in  the  Tren- 
delenburg position  and  the  operation  completed  through  a  large  abdominal 
incision,  as  before  outlined. 

The  after-treatment  is  the  same  as  before  described. 

VAGINAL  HYSTERECTOMY  FOR  NON-MALIGNANT  CONDITIONS 

In  severe  uterine  hemorrhage,  due  to  the  presence  of  small  uterine  fibroids, 
which  cannot  be  controlled  by  means  of  simpler  methods,  a  vaginal  hysterec- 
tomy is  indicated  because  of  its  easy  execution,  that  it  does  not  give  rise  to  a 
scar  and  is  as  safe  as  the  abdominal  method.  In  this  case  it  is  not  necessary 
to  make  the  vaginal  incision  by  means  of  the  cautery.  The  remaining  steps  of 
the  operation  are  the  same  as  in  vaginal  hysterectomy  for  carcinoma,  but  there 
is  no  necessity  for  leaving  the  pressure  forceps  in  place,  and  the  patient's  com- 
fort is  increased  by  applying  a  ligature  around  the  portion  of  the  pedicle 
containing  the  uterine  artery,  as  indicated  in  plate,  and  a  second  ligature 
around  the  remaining  portion  of  the  pedicle,  as  next  shown,  so  that  two  liga- 
tures will  take  the  place  of  the  two  pressure  forceps  in  the  operation  which 
has  just  been  described.  The  ligatures  should  be  passed  through  the  pedicle 
in  a  manner  which  will  prevent  their  slipping,  because  a  careless  application 
of  ligatures  at  this  point  might  result  in  a  dangerous  hemorrhage.  Two  catgut 
stitches  are  inserted  through  the  edge  of  the  wound  to  one  side  of  the  center 
and  left  untied,  as  indicated,  until  the  tampon  of  iodoform  gauze  has  been 
fastened  to  each  of  the  two  lateral  pedicles  by  means  of  a  small  catgut  stitch, 


SURGERY  OF  THE  FEMALE  PELVIS 


641 


as  shown.  The  tampon  should  then  be  shoved  up  into  the  abdominal  cavity, 
together  with  the  two  lateral  pedicles,  and  then  the  stitches  in  the  wound  are 
tied.  This  provides  for  the  approximation  of  the  two  lateral  pedicles  and  for 
the  closure  of  the  vaginal  wound,  and  also  for  a  sufficient  amount  of  capillary 
drainage.  The  approximation  of  the  lateral  pedicles  is  especially  valuable  in 
case  the  operation  is  performed  for  the  relief  of  complete  prolapsus  of  the 


Uterine  Cakcinoma. 

uterus,  because  in  this  manner  a  support  for  the  floor  of  the  pelvis  is  provided. 
A  retention  catheter  is  inserted  as  before  and  the  after-treatment  is  carried 
out  in  the  same  manner,  the  iodoform  gauze  tampon  being  removed  between 
the  fifth  and  tenth  day  after  the  operation. 

In  carcinoma  of  the  uterus  which  is  operated  early,  before  the  disease  has 
advanced  beyond  the  tissues  of  the  cervix,  this  operation  is  also  very  satis- 
factory, but  in  cases  which  have  advanced  beyond  the  incipient  stage  we  have 
had  more  satisfactory  results  when  we  have  used  the  clamp. 


642  SURGERY  OF  THE  FEMALE  PELVIS 

In  place  of  using  the  ordinary  hemostatic  clamps  we  have  used  Doud's  elec- 
tric cautery  clamp  in  many  cases.  This  clamp  is  applied  to  the  pedicle  as  one 
would  apply  an  ordinary  clamp,  then  a  current  of  electricity  is  passed  through 
the  instrument  for  fifteen  to  thirty  seconds,  which  thoroughly  cooks  the  tissues 
contained  in  its  bite.  This  at  once  secures  the  pedicle  against  hemorrhage  and 
destroys  any  malignant  tissue  which  may  be  contained  in  the  pedicle. 

The  same  clamp  is  used  upon  the  pedicle  formed  by  the  broad  ligament  in 
the  abdominal  operation.  By  using  this  clamp  the  entire  operation  can  be  per- 
formed without  the  use  of  either  knife  or  ligature,  the  entire  surface  being 
covered  with  cauterized  tissue.  The  results  after  operations  performed  with 
the  use  of  this  instrument  have  been  most  satisfactory. 

The  patients  do  not  suffer  from  shock,  neither  do  they  suffer  from  severe 
pain  after  the  operation.  It  is  well  to  mention  these  facts  because  they 
dispose  of  theoretical  objections  that  might  arise. 

PROLAPSE  OF  THE  UTERUS 

In  prolapsus  of  the  uterus  in  patients  advanced  in  years,  in  which  the 
tissues  of  the  broad  ligament  seem  to  be  fairly  substantial,  the  operation  which 
has  just  been  described,  performed  without  the  use  of  the  cautery  clamp,  has 
given  most  satisfactory  results.  If,  however,  the  entire  vaginal  mucous  mem- 
brane, together  with  the  posterior  wall  of  the  bladder  and  the  anterior  wall  of 
the  rectum,  show  a  tendency  to  prolapse,  these  latter  structures  are  likely  to 
continue  to  descend  after  doing  the  operation  above  outlined,  and  in  such  the 
patients  will  be  but  slightly  improved  unless  a  more  extensive  procedure  is 
chosen. 

The  operation  which  seems  to  invariably  give  relief  in  these  cases  consists  in 
the  additional  removal  of  the  entire  vaginal  mucous  membrane  and  the  closure 
of  the  entire  canal  by  means  of  buried  catgut  sutures.  The  operation  which 
has  just  been  described  is  performed  without  the  use  of  the  cautery  clamp,  and 
with  the  exception  that  the  two  lateral  pedicles  are  united  to  each  other 
broadly  by  means  of  buried  chromicized  catgut  sutures,  and  then  the  entire 
mucous  lining  of  the  vagina  is  dissected  out  from  above  downward,  leaving  a 
raw  canal  throughout.  This  is  closed  by  a  series  of  buried  catgut  sutures  from 
above  downward,  and  at  last  the  skin  at  the  entrance  of  the  vagina  is  united 
by  means  of  a  longitudinal  suture  extending  from  a  point  two  centimeters 
above  the  meatus  urinarius  down  to  the  anterior  edge  of  the  perineum.  In 
applying  the  buried  catgut  sutures  it  is  important  that  neither  the  rectum  nor 
the  bladder  be  wounded,  for  fear  of  producing  a  recto-vesical  fistula. 

The  after-treatment  is  the  same  as  after  an  ordinary  abdominal  section. 

Prognosis.  The  prognosis  in  this  operation  is  very  favorable.  In  prolapsus 
of  the  uterus  in  younger  patients  it  is  usually  found  that  the  displacement  is 
due  to  an  abnormal  elongation  of  the  cervix.  There  seems  to  be  a  tendency  on 
part  of  the  tissues  of  the  vagina  to  make  traction  upon  the  elongated  cervix 
and  thus  cause  a  prolapsus  of  the  uterus.  The  replacement  of  the  latter  is 
of  no  apparent  benefit  to  the  patient,  and  the  support  by  means  of  pessaries 
seems  to  be  of  no  avail.  If,  however,  the  following  operation  be  employed  for 
the  purpose  of  removing  the  elongated  cervix  the  broad  ligaments  seem  to  be 
able  to  support  the  uterus  in  its  normal  position,  and  the  organ  will  remain  in 
its  proper  position  without  any  further  support. 

REMOVAL  OF  ELONGATED  CERVIX 

A  circular  incision  is  made  about  the  end  of  the  elongated  cervix  and  the 
mucous  membrane  surrounding  the  latter  is  reflected  to  a  point  a  little  below 


SURGERY  OF  THE  FEMALE  PELVIS 


643 


the  upper  extremity  thereof.  This  point  may  be  at  a  considerable  distance 
from  the  lower  end  of  the  cervix,  as  shown  in  the  plate,  which  was  drawn  from 
nature,  and  in  which  the  cervix  had  reached  the  length  of  twelve  centimeters. 
Upon  a  casual  examination  it  seemed  as  though  there  were  a  prolapse  of  the 
entire  uterus,  but  upon  careful  inspection  it  was  found  that  only  the  elongated 
cervix  projected.  The  mucous  membrane  was  carefully  dissected  upwards  in 
the  anterior  and  posterior  flap,  as  indicated,  and  severed  just  below  the  upper 
extremity  of  the  cervical  canal.    As  soon  as  this  portion  of  the  cervix  had  been 


Excision  of  Elongated  Cervix  L'teri. 


The  elongated  cervix  (a)    (b)    withdrawn 
from  the  vaginal  orifice. 


The  mucous  membrane  covering  the 
cervix  has  been  reflected  by  making 
an  elliptical  incision  around  the  cervix 
(a).  Thus  an  anterior  (h)  and  a  pos- 
terior (c;  mucous  flap  are  formed  and 
the  projecting  cervix  is  amputated. 

cut  away  the  uterus  showed  a  tendency  to  slip  up  into  the  pelvic  cavity,  and 
had  to  be  held  down  in  position  in  order  to  complete  the  operation,  which  con- 
sisted in  covering  the  stump  with  the  mucous  membrane  removed  from  the 
portion  of  the  cervix  cut  away,  as  shown.  This  method  insures  the  formation 
of  a  normal  cervix. 

As  has  been  stated  before,  the  uterus  showed  a  tendency  to  slip  up  into  the 
pelvis  and  take  up  a  normal  position  as  soon  as  it  was  released  from  below, 
even  in  this  greatly  exaggerated  case.  This,  however,  is  not  the  history  in 
patients  advanced  in  years  who  have  given  birth  to  a  number  of  children.  In 
these  the  hysterectomy  which  has  just  been  described  is  to  be  preferred. 

In  cases  in  which  an  obliteration  of  the  vagina  is  not  desirable  it  is  best  to 
perform  the  abdominal  hysterectomy  described  elsewhere,  especial  care  being 
taken  to  construct  a  substantial  floor  for  the  vagina  by  firmly  suturing  together 


644 


SURGERY  OF  THE  FEMALE  PELVIS 


the  broad  and  the  round  ligaments  with  chromic  catgut.  This  can  be  done  to 
the  required  degree  by  carefully  overlapping  these  ligaments.  At  the  same 
time  it  is  wise  to  suture  together  broadly  the  recti  muscles  throughout  the 
abdominal  incision. 


Closure  of  Worxi)  in  Cervix. 

The  flaps  of  niueous  membrane  are  brought  down  over  the  stump,  sutured  to  the  mucous 
membrane  lining  the  uterine  cavity,  and  all  raw  surfaces  are  covered  with  portions  of  the 
Jiucous  membrane,  making  a  perfectly  uniform  stump  (a). 

EROSION  OF  THE  CERVIX 

In  many  patients,  but  especially  in  those  whose  occupation  compels  them 
to  stand  a  greater  part  of  the  day,  the  pressure  of  the  cervix  upon  the  tissues 
upon  which  it  rests  causes  a  condition  of  erosion,  which,  in  turn  results  in  the 
formation  of  exceedingly  hard,  cicatricial  tissue.  This  condition  is  most  com- 
mon in  women  who  have  borne  children,  because  in  these  the  uterus  has  usually 
not  undergone  complete  involution,  and  the  consequent  increase  in  weight 
increases  the  pressure  and  thus  favors  the  result  in  question. 

The  pressure  occurring  from  the  contraction  of  the  cicatricial  tissue  is 
likely  to  produce  the  symptoms  described  in  connection  with  laceration  of  the 
cervix,  and  the  same  treatment  is  indicated. 


LACERATION  OF  THE  CERVIX 

Causative  factors  and  symptoms.  In  a  considerable  proportion  of  patients 
going  through  childbirth  the  cervix  of  the  uterus  is  lacerated.  If  the  wound 
is  not  kept  aseptic  the  healing  is  bound  to  be  slow,  and  there  must  result  a 
variable  amount  of  connective  tissue.  In  a  second  delivery  the  tissues  are  less 
elastic  than  normal,  because  of  the  presence  of  this  cicatricial  tissue,  and  there- 
fore a  further  laceration  is  almost  certain  to  occur,  which  is  apt  to  be  more 
extensive  than  the  previous  one.  Where  the  patient  can  obtain  reasonable 
care  during  the  pregnancy,  and  during  and  after  confinement,   the  wound 


SURGERY  OF  THE  FEMALE  PELVIS  645 

usually  heals  so  perfectly  that  it  requires  no  further  attention,  but  unfor- 
tunately there  is  a  large  class,  comprising  the  most  valuable  women  in  the 
country,  in  which  conditions  are  such  that  ideal  care  during  pregnancy  and 
during  the  after-confinement,  is  not  possible.  This  class  comprises  the  wives 
of  the  mechanics,  artisans,  farmers  and  laborers. 

Customary  history.  The  patient  usually  gives  a  history  of  having  been  in 
excellent  health  at  the  time  of  her  marriage,  of  having  undergone  a  variable 
number  of  normal  pregnancies  and  usually  a  certain  number  of  abortions  •  the 
confinement  has  generally  been  conducted  by  a  midwife;  the  patient  has' felt 
the  necessity  of  caring  for  her  entire  household  during  her  pregnancy;  she 
has  had  but  a  slight  amount  of  care  during  and  after  confinement ;  she  has  not 
enjoyed  the  benefits  of  a  trained  nurse  at  such  time;  she  began  to  perform 


Amputation  of  Lacerated  Cervix  Uteri. 

The  uterus  is  drawn  down  with  volsellum  forceps  (b).  An  ellij^tical  incision  is  made 
around  the  cervix.  The  anterior  portion  (e)  is  dissected  down  to  the  cervical  canal.  Then 
sutures  (c)  and  (d)  are  inserted,  uniting  the  vaginal  with  the  cervical  mucous  membrane. 
These  are  left  untied  until  the  lateral  sutures  have  been  applied.  Then  the  removal  of  the 
cervix  is  completed. 

her  regular  labors  within  a  short  period  after  confinement ;  and  had  the  care 
of  her  infant  and  all  of  her  family  within  a  short  time  thereafter.  Usually 
the  first  confinements  made  no  marked  impression,  but  later  on  the  patient 
apparently  began  to  grow  old  rapidly;  to  suffer  from  the  sensation  of  weight 
in  the  pelvis,  and  from  pain  low  down  in  the  back ;  and  she  usually  complains 
of  feeling  tired  most  of  the  time.  Constipation  and  lack  of  strength  in  secur- 
ing evacuation  of  the  bowels  are  usually  complained  of.  Notwithstanding 
this,  the  patient  frequently  has  gained  in  weight,  her  abdominal  walls  have 
become  greatly  thickened  with  the  accumulation  of  this  fat,  but  the  normal 
tone  of  the  abdominal  walls  has  been  lost.  Later  on  the  patient  has  complained 
of  nervousness,  has  become  irritable,  her  digestion  is  impaired,  and  this  con- 
dition frequently  continues  until  she  is  nearly,  if  not  wholly,  bed-ridden. 

Upon  examination  the  perineal  support  of  the  uterus  is  found  to  be  greatly 
impaired,  the  vaginal  walls  are  loose  and  flabby,  the  cervix  is  greatlj'  thick- 


646 


SURGERY  OF  THE  FEMALE  PELVIS 


ened  and  edematous,  and  in  a  majority  of  patients  there  is  a  laceration  of  the 
left  side.  Occasionally  there  are  several  other  lacerations  of  the  cervix,  all 
filled  with  hard,  cicatricial  tissue.  The  uterus  is  found  upon  bi-manual  exami- 
nation to  be  considerably  hj^pertrophied,  sometimes  twice  or  thrice  the  normal 
size — involution  not  having  taken  place  after  the  confinements  and  abortions. 
The  fundus  of  the  uterus  may  be  retroverted  or  it  may  be  in  a  nearly  normal 
position.  The  entire  organ  is  likely  to  be  somewhat  prolapsed  and  displaced 
backward. 

Preparatory  treatment.  This  should  be  the  same  as  for  any  ordinary 
operation,  unless  the  cervix  is  covered  by  a  septic  ulcer.  In  such  instance,  it 
is  Avise  to  place  her  in  bed  for  a  few  days  before  the  operation  is  performed. 


Amputation  of  Cervix  Uteri  for  Laceration. 

(b),  (c),  (d)  and  (e)  represent  the  sutures  which  unite  the  mucous  membrane  of  the 
vagina  with  that  of  the  cervical  canal,  preventing  closure  of  the  latter;  (t)  (gj  and  (h)  (i) 
lepresent  the  sutures  on  either  side  which  cover  the  raw  surface  resulting  from  the  excision 
of  the  cervix. 


to  give  large,  very  hot  douches  from  three  to  six  times  a  day,  and  at  night 
apply  some  antiseptic,  such  as  compound  tincture  of  iodine,  equal  parts  of 
compound  tincture  of  iodine,  glycerine  and  carbolic  acid,  or  a  tampon  of 
twenty-five  per  cent,  ichthyol  in  glycerine.  During  this  period  of  treatment 
the  patient  should  also  receive  mild  laxatives  and  light  diet. 

Operative  technique.  The  treatment  we  have  found  most  valuable  in  these 
cases  consists  in  the  removal  of  all  of  the  hardened  tissue  in  the  cervix  and 
then  covering  the  abraded  surface  with  vaginal  mucous  membrane.  A  broad 
vaginal  speculum  is  introduced,  as  shown  in  the  plate,  and  a  volsellum  forceps 
applied  to  the  posterior  lip  of  the  cervix.  With  this  it  is  drawn  downward  and 
a  little  forward,  and  an  elliptical  incision,  including  all  the  hardened  tissue 
in  the  cervix,  is  made  with  a  sharp  scalpel.  The  posterior  lip  is  not  entirely 
severed  during  this  stage,  but  the  anterior  lip  is  severed  down  to  the  cervical 
canal.  Then  two  chromicized  catgut  stitches  are  applied  to  the  anterior  lip 
in  the  following  manner:     One-eighth  of  an  inch  of  vaginal  mucous  mem 


SURGERY  OF  THE  FEMALE  PELVIS 


647 


brane  is  grasped  with  a  short-curved  needle,  as  shown.  The  needle  at  the  same 
time  grasps  about  one-third  of  the  thickness  of  the  underlying  muscle  •  then  it 
is  reintroduced  into  the  cervical  tissue  and  the  same  amount  of  tissue  includ- 
ing the  mucous  membrane  lining  the  cervix,  is  grasped  with  these  'sutures. 
These  sutures  are  then  left  untied  until  the  remaining  portion  of  the  operation 
has  been  completed,  when  their  tying  will  approximate  perfectly  the  vaginal 
mucous  membrane  and  that  lining  the  cervical  canal.  These  two  sutures  will 
serve  to  manipulate  the  uterus  during  the  remainder  of  the  operation.  The 
hardened  tissue  is  now  completely  cut  away,  leaving  the  cervix  as  shown  in 
plate.  Two  further  sutures  are  inserted  posteriorly,  corresponding  to  those 
applied  anteriorly  before  the  cervix  was  entirely  cut  away.  These  are  also 
left  untied.  Two  additional  sutures  are  then  passed  on  each  side,  grasping  the 
mucous  membrane  in  front;  then  to  the  substance  of  the  cervix  to  each  side 


Amputation  of  Cervix  Uteri. 

This  plate  shows  the  operation  as  completed  after  all  of  the  sutures  have  been  tied  and 
superficial  sutures  have  been  inserted  to  secure  accurate  coaptation  of  the  mucous  membrane. 

of  the  cervical  canal ;  then  to  the  mucous  membrane  behind.  After  all  of  these 
sutures  have  been  applied  they  are  tied  successively,  the  outer  ones  being  tied 
first ;  the  two  sutures  grasping  both  the  vaginal  and  the  cervical  mucous  mem- 
branes being  left  to  the  last.  After  all  of  these  have  been  tied  the  entire 
abraded  surface  will  be  covered,  with  the  addition  of  a  few  coaptation  sutures, 
as  indicated  in  the  plate. 

This  leaves  the  cervix  in  as  nearly  an  ideal  condition  as  possible,  and  in 
case  of  a  future  pregnancy  it  is  no  more  likely  to  become  lacerated  than  it 
would  be  had  it  never  had  a  laceration  and  the  reparative  operation.  In  quite 
a  considerable  number  of  patients  we  have  observed  the  outcome  after  a  future 
confinement,  and  in  all  of  these  the  condition  has  been  most  satisfactory. 

The  chromicized  catgut  to  be  used  should  be  prepared  so  as  to  absorb  within 
about  two  weeks.  This  will  dispose  of  the  annoyance  of  removing  the  stitches. 
It  is  important  in  this  operation  that  the  stitches  be  not  drawn  too  tightly, 
as  a  certain  amount  of  edema  is  sure  to  occur,  which  is  greatly  increased  if  the 


648  SURGERY  OF  THE  FEMALE  PELVIS 

stitches  are  tied  tightly.  In  this  event  each  stitch  will  leave  a  line  of  pressure- 
necrosis  across  the  surface  to  be  occupied  by  hard  nodular  tissue.  The  removal 
of  the  hard  connective  tissue  is  the  most  important  benefit  the  patient  derives, 
and  consequently  nothing  should  be  done  in  the  operation  which  might  give 
rise  to  a  recurrence  of  this  state,  even  to  a  slight  extent. 

After  the  wound  has  healed  the  surface  should  be  perfectly  soft  and 
covered  with  loose  connective  tissue,  and  the  impression  upon  making  a  digital 
examination  should  be  very  similar  to  that  one  obtains  in  making  an  examina- 
tion of  a  cervix  which  has  not  been  disturbed  by  pregnancy  or  confinement. 

After  the  operation  has  been  completed  the  uterus  should  be  replaced  in 
the  normal  position  by  bi-manual  manipulation.  It  frequently  happens  that 
during  operations  the  uterus  has  been  drawn  down  considerably,  and  after 
the  work  is  completed  it  is  quite  out  of  place,  and  unless  the  surgeon  takes 
the  precaution  of  properly  replacing  the  organ  at  the  conclusion  of  his  opera- 
tion it  may  remain  displaced  during  the  entire  time  the  patient  is  confined  to 
bed.    In  this  way  considerable  harm  may  follow. 

The  after-treatment  consists  of  rest  in  bed  for  at  least  two  weeks ;  the 
administration  of  from  three  to  six  large,  hot  douches  a  day ;  a  light  diet, 
and  the  use  of  mild  laxatives. 

In  almost  all  of  these  patients  there  are  other  conditions  which  must  be 
corrected,  and  the  prognosis  will  be  considered  in  connection  with  them. 

LACERATION  OF  THE  PERINEUM 

This  deformity  almost  invariably  accompanies  the  condition  just  described, 
although  if  the  patient  has  had  the  care  of  a  physician  during  confinement 
the  laceration  is  nowadays  usually  repaired  at  once  after  its  o.ccurrence ;  con- 
sequently there  are  comparatively  few  old  lacerations  now  in  patients  who 
have  this  proper  attention.  These  cases  belong  to  a  class  in  which  the  lacera- 
tions occurred  at  a  time  when  the  general  practitioner  was  not  so  careful  to 
examine  and  repair  a  torn  perineum  after  confinement  as  he  is  to-day,  and  in 
the  class  still  being  confined  by  the  midwife. 

The  history  is  the  same  as  that  just  given  in  comiection  with  laceration 
of  the  cervix.  The  laceration  may  vary  in  degree,  extending  quite  into  the 
rectum  for  a  slight  distance,  or  for  several  inches,  or  only  through  a  portion  of 
the  perineal  body,  or  only  through  the  upper  or  the  lower  portion — which  may 
be  determined  upon  inspection  or  by  making  a  digital  examination.  There  may 
exist  at  the  same  time  a  bulging  forward  of  the  rectum  between  the  margins  of 
the  lacerated  tissues,  the  mucous  membrane  of  the  vagina  and  the  wall  of  the 
rectum  being  carried  forward  by  the  pressure  of  the  feces  in  the  latter,  form- 
ing a  rectocele.  If  this  condition  be  present  it  usually  interferes  very  seriously 
with  the  evacuation  of  the  bowels. 

In  some  cases  the  skin  and  mucous  membrane  may  have  remained  per- 
fectly intact,  and  still  with  virtually  no  perineal  support  left,  because  while 
the  skin  and  mucous  membrane  were  not  injured,  on  account  of  their  elasticity, 
the  transverse  perineal  muscles  were  completely  torn  and  the  levator  ani 
muscles  separated. 

Operative  technique.  A  transverse  incision  is  made  through  the  septum 
remaining  between  the  rectum  and  vagina,  and  the  tissues  of  the  vaginal  wall 
carefully  dissected  loose  from  those  of  the  rectal  wall,  forming  a  large  flap, 
which  is  carried  forward  into  the  vagina — the  entire  septum  being  split  from 
side  to  side.  After  the  incision  through  the  skin  and  through  a  short  distance 
of  cicatricial  tissue  which  usually  exists  underneath  the  skin,  the  separation 
of  these  flaps  may  be  accomplished  most  readily  by  grasping  the  vaginal  flap 
with  dissecting  forceps  and  shoving  away  this  section — the  posterior  flap — 


SURGERY  OF  THE  FEMALE  PELVIS 


649 


by  means  of  the  finger,  covered  with  several  layers  of  moist  aseptic  gauze.  In 
this  manner  a  flap,  as  shown  in  the  plate,  can  be  produced  in  a  few  moments. 
This  exposes  the  tissues  on  each  side  which  originally  formed  the  perineum, 


Pekineorrhapht. 

The  recto-vaginal  septum  has  been  split  and  the  vaginal  flap  (e)  drawn  forward.  A 
silkworm  gut  suture  (aa)  has  been  applied  to  the  anterior  flap,  which,  when  tied,  will  make 
a  new  floor  for  the  vagina.  A  similar  suture  (b)  is  applied  to  the  posterior  flap.  These 
sutures  extend  to,  but  not  through,  the  mucous  membrane  in  either  case.  The  sutures  caught 
in  the  forceps,  marked  (c),  pass  through  the  lateral  flaps,  but  they  are  left  untied  until  each 
successive  tissue  on  either  side  has  been  united  with  the  same  tissue  on  the  opposite  side  by 
means  of  the  continuous  cat-gut  suture  marked  (d).  After  the  deep  tissues  have  been  united 
with  the  silkworm  gut  sutures  (c)  are  tied. 

and  by  carefully  uniting  these,  after  the  manner  to  be  described,  a  perineum 
may  be  constructed  which  will  be  as  thorough  a  support  as  the  original 
structure.  The  anterior  flap  is  drawn  forward  and  a  row  of  interrupted  ten- 
sion sutures   applied,   as  indicated  in  the  plate,  the  first  suture  beginning 


650  SURGERY  OF  THE  FEMALE  PELVIS 

directly  underneath  the  skin  and  grasping  the  submucous  tissues  successively 
and  issuing  on  the  opposite  side  directly  underneath  the  skin.  The  last  suture 
posteriorly  is  applied  precisely  in  the  same  manner. 

It  will  be  seen  that  after  the  first  suture  has  been  tied  there  will  be  a 
perfect  floor  to  the  vagina,  no  matter  how  deep  the  laceration  may  have  been. 
The  same  is  true  after  the  last  stitch  posteriorly  has  been  tied,  there  will  be  a 
new  roof  for  the  rectum,  even  though  the  laceration  may  have  extended  a 
considerable  distance  up  into  the  same.  It  is  plain  that  if  these  two  stitches 
are  properly  applied  that  a  recto-vaginal  fistula  after  this  operation  is 
impossible. 

The  remaining  deep  stitches  are  inserted  through  the  tissues  on  each  side, 
beginning  near  the  skin  and  passing  down  to  a  point  just  in  front  of  the  rec- 
tum, then  passing  over  to  the  other  side  in  front  of  the  rectum  and  out  through 
the  tissues  precisely  opposite  to  the  manner  of  introduction  on  the  other  side. 
From  two  to  five  of  these  sutures  are  inserted  and  left  untied.  Ordinary  cat- 
gut sutures  would  undoubtedly  suffice  for  this  purpose,  but  in  our  practice 
we  have  used  chromicized  catgut,  which  will  be  absorbed  after  about  twenty 
days.  A  continuous  catgut  suture  is  then  introduced,  as  shown,  for  the  pur- 
pose of  uniting  the  tissues  on  one  side  to  the  corresponding  tissues  on  the 
opposite,  a  small  bite  being  taken  with  a  short,  curved  needle  and  care  being 
exercised  to  avoid  wounding  the  rectum. 

It  is  important,  again,  to  draw  these  stitches  very  loosely,  for  fear  of  caus- 
ing pressure-necrosis.  The  suturing  can  be  done  from  above  downward,  then 
from  below  upward,  then  from  above  downward  again,  the  same  suture  being 
used  continuously. 

After  all  the  tissues  have  been  placed  in  accurate  coaptation  in  this  man- 
ner, the  continuous  suture  is  tied  and  then  the  stay  sutures  are  tied  loosely 
over  this,  and  then  the  skin  is  united  carefully  with  a  continuous  catgut  suture. 
It  is  clear  that  a  rectocele  cannot  occur  after  this  operation,  because  the  space 
originally  occupied  by  the  rectocele  is  completely  filled  in  by  the  sutures.  This 
operation  will  give  satisfactory  results  with  any  one  of  the  various  forms  of 
laceration  of  the  perineum  enumerated  above. 

Concomitant  hemorrhoids.  A  considerable  number  of  these  patients  suffer 
at  the  same  time  from  hemorrhoids.  It  is  usually  sufficient  simply  to  dilate  the 
sphincter  ani  muscles  thoroughly  before  this  operation  is  performed,  in  order 
to  relieve  the  patient  of  that  trouble.  In  cases  where  there  are  hemorrhoids 
of  considerable  size,  however,  the  operation  already  described  should  be  em- 
ployed, but  the  hemorrhoids  on  the  anterior  surface  of  the  rectum  should  not 
be  disturbed  for  fear  of  causing  an  infection  of  the  perineal  wound.  In  case 
a  hemorrhoidal  swelling  is  directly  on  the  anterior  surface  of  the  rectum,  this 
invariably  disappears  after  the  perineum  has  been  repaired,  which  is  not 
always  the  case  with  those  located  on  the  lateral  or  the  posterior  surfaces  of 
the  rectum,  hence  the  latter  should  be  removed  with  clamp  and  cautery,  or 
with  the  ligature. 

After-treatment.  The  patient  should  remain  in  bed  for  at  least  two  weeks, 
and  if  possible  it  is  better  to  have  her  remain  a  week  or  two  longer,  because 
the  benefit  derived  from  perfect  rest  is  quite  important,  and  if  this  be  pro- 
longed somewhat  it  is  quite  worth  while.  Many  of  these  patients  also  suffer 
from  gastric  disturbances ;  consequently  they  are  greatly  benefited  by  careful 
dieting,  which  may  be  carried  out  during  their  stay  in  the  hospital  without 
interfering  with  the  progress  of  the  recovery  from  the  operation.  "We  have 
found  that  many  suffer  at  the  same  time  from  an  inability  to  masticate  their 
food  properly,  because  during  their  long-continued  illness  they  have  not  given 
needful  attention  to  the  preservation  of  the  teeth.  Among  the  class  of  work- 
ing women  in  whom  these  operations  are  especially  indicated  one  frequently 
finds  the  mouth  filled  with  decayed  roots,  and  it  is  consequently  a  good  plan 


SURGERY  OF  THE  FEMALE  PELVIS 


651 


invariably  to  examine  the  teeth  and  during  the  anesthesia  remove  any  decayed 
roots  that  may  be  present,  and  to  direct  these  patients  after  recovery  from 


/ 


Excision  of  Urethra. 

The  urethra  has  been  dissected  out  and  drawn  forward  with  forceps  and  partly  severed. 
The  remaining  stump  is  being  sutured  to  the  skin  with  interrupted  cat-gut  sutures,  two 
sutures  being  in  place  and  the  third  one  being  applied. 


their  operations  to  have  the  remaining  teeth  thoroughly  repaired,  and  if  there 
are  many  missing  to  procure  artificial  dentures.  This  will  also  aid  in  building 
up  these  sufferers  very  greatly  after  the  return  home  from  their  operations. 


652  SURGERY  OF  THE  FEMALE  PELVIS 

These  patients  should  be  especially  cautioned  against  constipation,  as  this 
will  aid  greatly  in  securing  a  satisfactory  recovery.  If  these  various  precau- 
tions are  taken  the  jDrognosis  is  usually  very  satisfactory.  A  worn-out  woman 
between  the  age  of  thirty-five  and  forty-five  years  usually  recovers  to  such  an 
extent  that  within  a  year  or  two  she  will  readily  be  taken  to  be  five  or  ten 
years  younger  than  she  was  before  the  operation. 

In  many  of  these  cases  there  is  at  the  same  time  a  retroversion  or  retro- 
flexion of  the  uterus,  which  may  easily  be  corrected  by  making  bimanual 
manipulations,  but  in  which  the  uterus  will  not  maintain  its  corrected  positioji 
for  any  considerable  length  of  time. 

Both  of  the  operations  which  have  .just  been  described  must  usually  be 
performed  on  the  same  patient.  The  result  of  the  amputation  of  the  cervix 
will  be  primarily  to  remove  an  amount  of  irritating  cicatricial  tissue,  to  remove 
a  suppurating  ulcerated  surface,  and  this  in  turn  will  result  in  the  natural 
absorption  of  the  hypertrophy  of  the  uterus,  which  is  present  at  the  time  of 
the  operation.  Within  a  few  months  an  hypertrophied  uterus  upon  which  this 
operation  has  been  performed  will  usually  be  reduced  to  an  almost  normal 
size.  This  in  itself  will  increase  the  probability  of  the  organ  remaining  in  its 
normal  position.  Then,  further,  the  repair  of  the  perineum  will  increase  this 
likelihood  still  more,  by  supphdng  additional  support  for  the  uterus.  If,  how- 
ever, the  retroversion  or  retroflexion  persists  after  these  operations  or  if  the 
tendency  to  these  displacements  is  so  great  that  it  does  not  seem  likely  that 
they  will  be  corrected  by  means  of  these  two  operations,  then  a  third  procedure 
is  indicated  for  the  direct  relief  of  this  condition. 

ALEXANDER  OPERATION 

In  cases  in  which  this  tendency  to  retroversion  and  retroflexion  exists  the 
round  ligaments  which  normally  hold  the  uterus  forward  have  been  so  severely 
stretched  that  they  are  no  longer  able  to  furnish  normal  support. 

An  incision  three  centimeters  in  length  is  made  directly  over  the  external 
abdominal  ring  in  the  direction  of  the  inguinal  canal.  It  is  carried  down 
through  the  skin  and  deep  fascia  to  the  fascia  of  the  external  oblique  abdom- 
inal muscle.  It  is  important  that  this  incision  be  carried  quite  through  the 
deep  fascia,  because  if  any  portion  of  this  fascia  is  permitted  to  remain  un- 
divided the  surgeon  may  experience  considerable  difficulty  in  locating  the 
round  ligament. 

After  the  fascia  of  the  external  oblique  has  been  thoroughly  exposed,  the 
external  abdominal  ring  can  be  located  by  palpation,  as  it  gives  the  feeling 
of  less  resistance  at  this  point  than  at  any  other.  The  fascia  of  the  external 
oblique  is  now  split  in  the  direction  of  its  fibers  at  this  point,  which  will  expose 
a  small  mass  of  fat  directly  in  the  external  abdominal  ring.  If  this  mass  of 
fat  is  now  grasped  by  means  of  a  pair  of  hemostatic  forceps,  it  will  contain 
the  round  ligament,  which  may  appear  as  a  thread-like  band,  or  may  take  the 
form  of  a  cord  of  considerable  size,  sometimes  as  large  as  two  millimeters  in 
diameter.  It  is  important  to  dissect  this  out  carefully,  because  if  once  lost 
it  may  be  difficult  to  find  it  again.  This  ligament  should  be  examined  care- 
fully, and  the  genital  branch  of  the  genito-crural  nerve  which  accompanies 
it  should  be  separated  as  its  destruction  results  in  a  paralysis  of  sensation 
in  the  parts  to  which  it  is  supplied — which  is  likely  to  be  the  cause  of  consid- 
erable annoyance. 

After  the  round  ligament  has  been  freed  from  its  connective  tissue  attach- 
ments, it  should  be  drawn  up  very  gently  until  the  infundibuliform  process 
of  the  peritoneum  becomes  apparent.     The  ligament  is  then  drawn  out  until 


SURGERY  OF  THE  FEMALE  PELVIS  653 

it  gives  the  sensation  of  drawing  the  uterus  against  the  abdominal  wall.  Then 
a  pad  of  sterile  gauze  is  passed  through  under  the  ligament  and  the  same 
steps  are  carried  out  on  the  opposite  side.  After  both  ligaments  have  been 
loosened  and  drawn  up  until  this  sensation  of  pulling  the  uterus  against  the 
abdominal  wall  is  felt  on  each  side,  then  each  is  relaxed  for  a  distance  of  about 
two  or  three  centimeters,  in  order  to  give  the  uterus  the  desired  mobility,  and 
a  few  stitches  of  fine  chromicized  catgut  are  passed  through  each  ligament, 
doubled  upon  itself  in  order  to  remove  the  slack  in  the  ligament.  Then  a  few 
stitches  are  inserted  between  the  doubled  ligament  and  the  posterior  surface 
of  the  fascia  of  the  external  oblique. 

In  case  the  inguinal  canal  has  been  stretched  during  the  operation,  the 
pillars  of  the  canal  are  drawn  together  by  a  few  stitches.  The  suturing  of 
the  fascia  of  the  external  oblique  abdominal  muscle  completes  the  operation. 

Much  has  been  written  concerning  the  likelihood  of  suppuration  taking 
place  in  these  operations.  We  believe  that  this  is  due  to  the  fact  that  a  con- 
siderable portion  of  the  operation  is  performed  upon  tissues  having  slight 
vitality,  and  if  with  these  the  surgeon  has  a  tendency  to  tie  his  sutures  too 
tight  the  resulting  pressure  necrosis  will  supply  an  excellent  culture  medium 
for  the  micro-organisms.  If  the  sutures  are  tied  just  tightly  enough  to  secure 
coaptation,  and  not  enough  to  cause  pressure-necrosis,  there  is  no  proneness 
towards  suppuration. 

After-treatment.  If  this  operation  is  performed  in  connection  with  the 
last  two  just  described,  no  special  after-treatment  will  be  required.  If  it  is 
done  for  the  relief  of  retroversion  or  retroflexion  of  the  uterus  in  cases  in 
which  there  is  no  indication  for  the  other  two  operations,  then  it  is  wise  for  the 
patient  to  wear  a  carefully-fitted  pessary  for  at  least  two  months  afterwards, 
so  that  the  adhesions  between  the  round  ligaments  and  their  new  attach- 
ments will  have  become  perfectly  firm  before  any  weight  is  placed  upon  them. 

Prognosis,  If  this  operation  is  undertaken  only  in  proper  cases,  namely, 
in  those  in  which  no  force  whatever  is  required  in  replacing  the  uterus  into 
its  normal  position,  cases  in  which  the  uterus  can  be  retained  in  its  normal 
position  by  means  of  a  carefully-applied  pessary,  the  prognosis  is  almost 
invariably  good.  Then  the  operation  does  not  interfere  with  a  future  preg- 
nancy, and  after  delivery  the  uterus  will  maintain  a  normal  position,  showing 
that  the  changes  during  pregnancy  have  no  tendency  to  destroy  the  benefits 
secured  for  the  patient  by  this  operation.  It  is  important,  we  believe,  that 
the  uterus  should  be  placed  in  the  normal  position  by  bi-manual  manipulation 
before  this  operation  is  done.  It  also  seems  important  that  the  round  ligaments 
should  not  be  shortened  too  much,  in  order  to  permit  the  normal  mobility 
of  the  uterus. 

VESICOCELE 

In  this  same  class  of  cases,  as  has  been  stated  above,  there  is  also  frequently 
an  injury  to  the  anterior  vaginal  wall,  as  well  as  to  the  posterior,  consisting 
in  a  separation  of  the  tissues  supporting  the  bladder  posteriorly.  As  a  result 
of  this  injury  the  bladder  will  bulge  into  the  vagina  more  and  more,  so  that 
in  extreme  cases  it  may  project  in  a  sac-like  protrusion  from  the  vagina.  This 
will  result  in  retention  of  a  certain  amount  of  urine,  in  obstruction  to  the 
passage  of  urine,  and  as  infection  of  this  residual  urine  is  likely  to  occur  this 
condition  usually  results  in  the  production  of  a  cystitis.  If  this  affection  is 
present  only  to  a  very  slight  extent,  the  operation  just  described  for  the  repair 
of  a  laceration  of  the  perineum  will  usually  suffice  to  support  the  bladder 


654 


SURGERY  OF  THE  FEMALE  PELVIS 


be 


2  '=^ 


be 


be  be 


SURGERY  OF  THE  FEMALE  PELVIS 


655 


a>       ^ 


H 

h-l 

fO 

^^ 

^ 

ri- 

O 

b' 

ce  Cp  op 

P 

!*>• 

W 

< 

En'  33 
0   p 

CD    0 

CO 

^ 

0 

r? 

i-S 

H 

0 

Cij 

rt 

sr 

P 

s 

■d 

K 

S' 

p 
0 

0 

P 

CO 

QfQ 

0 
■-i 

CD 

CD 

t-b  cc 
CU 

a> 

SL 

0 

r-l- 

w 

D" 

^ 

H 

(tl 

3 

S 

s- 

CD  aq 

CD 
Cfl 

0 

H 

V! 

p 

CD 

71 

Hrt 

Cli 

jply  enou 
ermanent 
formed  se 

^    CD 

""     C^J 

?§ 
CD    CD 

ct 

J4 

l-S 

2.    crq 


P 

^ 

'T^fiS     P 

P 

0 

CD 

Pi 

CD 

0 

P 

P 

H 

cn 

a 

H 

r. 

^■^ 

CD  OQ 

a' 

CD 

Pi 

CD 

0 

t3- 
CD 

Oi 

C5 

P 

P 

cfq 

r<- 

-^ 

P 

P 

CD 

i_j 

cl- 

CD 

^ 

P 

H 

0 
Hi 

m 
tf 

P 

cn 

PI 

H 

tr- 

rr 

CD 

CD 

B 

51 

C 

P 

0. 

n 
0 

t— 

M- 

0. 

I-" 

CD 

M 

n 

HbS 

gorq 

0 
>-i 

CD 

►73 

0 

h4i- 

P 

■d 

CD 

l-l 

CD 

(r+ 

pj  en     , 

2  5: 


656  SURGERY  OF  THE  FEMALE  PELVIS 

posteriorly,  and  as  a  consequence  the  s^^mptoms  resulting  from  the  vesicocele 
will  subside.  If  the  vesicocele  is  pronounced,  however,  this  operation  alone 
will  not  suffice.  It  will  then  become  necessary  to  excise  an  elliptical  portion 
of  the  anterior  vaginal  wall,  with  its  greater  diameter  extending  parallel  with 
the  direction  of  the  vagina.  This  will  expose  the  ends  of  the  torn  tissues. 
The  latter  may  be  united  by  a  continuous  suture  extending  parallel  with  the 
direction  of  the  vagina.  If  the  lacerated  tissues  are  thus  united  the  mucous 
membrane  of  the  bladder  will  contract  and  the  vesicocele  be  abolished.  It  is 
important,  however,  that  there  be  no  pressure  upon  the  sutures  shortly  after 
the  operation,  and  in  order  to  prevent  this  it  is  wise  to  insert  a  retention 
catheter  directly  after  the  operation,  which  Mall  insure  an  empty  bladder,  and 
consequently'  absence  of  pressure  upon  the  sutured  wound.  The  perineum 
should  be  sutured  simultaneously,  in  order  to  further  support  the  posterior 
wall  of  the  bladder. 

After-treatment.  The  patient  should  be  given  large  quantities  of  pure 
water  to  drink  so  as  to  dilute  the  urine  and  make  it  non-irritating,  and  pre- 
vent the  accumulation  of  phosphates  in  the  catheter.  A  large,  hot  douche 
should  be  given  from  three  to  six  times  a  day  to  keep  the  vaginal  wound 
clean.  In  all  other  respects  the  after-treatment  is  the  same  as  following  the 
operations  just  described. 

The  retention  catheter  is  removed  at  the  end  of  one  and  one-half  or  two 
weeks,  but  if  there  is  any  tendency  of  the  bladder  to  become  sufficiently  dis- 
tended to  stretch  the  wound  the  catheter  should  be  reintroduced. 

Prognosis.     The  prognosis  after  this  operation  is  satisfactory  unless  the 
deformity  has  existed  for  so  long  a  time  that  the  elasticity  of  the  mucous  mem-, 
brane  of  the  bladder  has  been  destroj-ed. 

EXCISION   OF   THE   LABIA   MAJORA,   MINORA   AND   CLITORIS   FOR 

CARCINOMA 

In  carcinoma  of  any  one  of  these  parts,  the  excision  of  the  entire  part, 
together  with  a  considerable  portion  of  the  surrounding  tissues,  is  indicated, 
but  the  most  important  portion  of  the  treatment  to  be  carried  out  consists  in 
the  careful  dissection  of  the  inguinal  lymphatic  glands,  an  operation  which 
has  been  described  in  connection  with  carcinoma  of  the  penis. 

In  our  own  work  we  have  employed  the  electro-cautery  or  the  Pacquelin 
cautery  for  the  removal  of  these  growths,  Avith  the  hope  of  preventing  the 
inoculation  of  surrounding  tissues  that  would,  or  might,  follow  the  knife. 
In  all  of  these  cases  it  is  important  to  dissect  away  the  fat  and  lymph  nodes 
of  the  inguinal  regions,  making  use  of  the  gauze  dissection  because  in  this 
way  recurrence  can  often  be  prevented. 

Prognosis.  A  very  extensive  and  thorough  operation  done  early  before 
the  disease  has  progressed  far,  promises  well  for  a  permanent  recovery,  which 
is  not  the  case  when  the  disease  is  greatly  advanced.  It  is  most  important  to 
make  a  very  extensive  operation  when  the  patient  first  comes  under  the  care 
of  the  surgeon,  even  though  the  area  involved  be  very  small. 

EXCISION  OF  THE  URETHRA 

This  operation  may  be  indicated  for  the  relief  of  epithelioma  of  the  meatus, 
a  condition  not  very  uncommon,  or  for  a  prolapsus  of  the  urethra.  If  it  is 
performed  for  the  relief  of  epithelioma  the  same  precautions  must  be  ob- 
served as  in  operations  for  the  relief  of  epithelioma  elsewhere.  A  sufficient 
amount  of  tissue  must  be  removed  to  insure  the  greatest  possible  freedom 
from  recurrence. 


SURGERY  OF  THE  FEMALE  PELVIS  657 

Technique.  A  circular  incision  is  made  around  the  urethra  for  a  sufficient 
distance  to  remove  all  diseased  tissues.  Then  the  urethra  is  dissected  out  up- 
wards towards  the  bladder  until  a  point  is  reached  a  sufficient  distance  from 
the  disease ;  then  the  remnant  of  the  canal  is  drawn  forward  and  a  stitch 
applied  between  this  and  the  outer  skin.  The  urethra  is  then  partly  cut  off 
transversel}^  and  a  second  stitch  applied  a  short  distance  from  the  first.  In 
this  manner  the  urethra  is  successively  stitched  to  the  skin  and  cut  off  until 
the  entire  structure  has  been  severed.  In  this,  as  in  every  operation  in  which 
a  tubular  structure  has  to  be  brought  foward  and  attached  to  the  skin,  it  is 
best  to  apply  a  few  stay  sutures  through  the  wall  of  the  tube  at  some  dis- 
tance back  from  the  outer  end.  and  to  attach  these  stitches  to  the  outer 
structures,  so  that  but  little  tension  is  left  for  the  stitches,  which  are  applied 
immediately  through  the  end  of  the  tube  and  through  the  skin.  In  :his  man- 
ner there  is  much  less  danger  of  retraction  from  the  tube  and  consequent  con- 
striction of  its  end  than  if  simply  a  single  row  of  sutures  is  employed. 

Should  it  seem  difficult  to  introduce  a  catheter  through  the  opening  for 
the  purpose  of  emptying  the  bladder  from  time  to  time  a  small  retention 
catheter  may  be  passed  while  the  patient  is  still  anesthetized.  This  catheter 
is  removed  after  a  few  days  and  the  patient  is  usually  able  thereafter  to  empty 
the  bladder  spontaneously. 

The  after-treatment  is  the  same  as  in  operation  for  cystocele. 

VESICO-VAGINAL  FISTULA 

Patients  suffering  from  this  condition  usually  give  a  history  of  a  long  con- 
tinued labor  with  or  without  the  use  of  forceps.  Following  'here  h;i>  u^ii-,illy 
been  retention  of  urine,  and  after  this  incontinence.  It  is  rare  that  a  lenkaa-e 
occurs  directly  after  the  deliver}^  indicating  that  a  rupture  of  the  bladder  has 
taken  place  at  that  time.  In  most  instances  the  bladder  wall  is  crushed  only 
sufficient  to  become  gangrenous  after  a  time,  but  will  support  the  urine  for 
several  days  after  the  confinement. 

Prophylaxis.  At  this  point  it  might  be  well  to  state  that  in  the^e  ca-5e>  the 
formation  of  the  fistula  might  frequently  be  prevented  if.  direetlv  af'er  a 
delivery  in  which  an  unusual  amount  of  pressure  occurred,  the  conditi^-n^;  were 
made  favorable  for  the  restoration  of  the  normal  vitality  of  the  crushed  tissues. 
This  would  be  greatly  assisted  by  the  introduction  of  the  retention  catheter, 
which  would  keep  the  bladder  constantly  empty  and  consequently  improve 
the  circulatory  conditions  in  this  organ  by  removing  the  intra-vesical  pressure. 
If,  however,  a  portion  of  the  posterior  bladder  wall  and  the  anterior  vaginal 
wall  have  sloughed  away  so  that  a  vesico-vaginal  fistula  has  occurred  nearly 
at  the  time  at  which  the  patient  comes  under  treatment,  relief  must  come 
from  repair  operation,  unless  the  fistula  be  very  small,  in  which  ca'=;e  simple 
continuous  drainasre  of  the  bladder  will  result  in  a  healing  of  the  openincr. 

Technique.  If  the  fistula  be  moderate  in  size  it  is  necessary  only  to  bring 
in  coaptation  relatively  broad  surfaces  in  order  to  secure  a  closure  of  the 
aperture.  This  can  be  accomplished  by  splitting  the  edge  of  the  fistula  in  its 
entire  circumference,  then  applying  a  row  of  fine  catgut  sutures  to  the  mucous 
membrane,  in  order  not  to  permit  any  portion  of  the  suture  to  project  into 
the  bladder.  A  second  row  of  sutures  is  applied  to  the  connective  tissue  layer 
between  the  vesical  and  the  vaginal  mucous  membrane.  A  third  row  of 
sutures  is  then  applied  to  the  vaginal  mucous  membrane.  The  bladder  is  then 
drained  Avith  a  retention  catheter  and  the  after-treatment  carried  out  as 
described  in  the  operation  for  vesicocele. 

Prognosis.  If  the  fistula  be  moderate  in  size  the  prognosis  is  almost  invari- 
ably good.    If,  however,  it  is  large  the  closure  must  be  accomplished  by  plastic 


658  SURGERY  OF  THE  FEMALE  PELVIS 


! 


operations,  portions  of  the  mucous  membrane  being  taken  from  various  parts 
apparently  most  suited  for  that  purpose,  but  if  the  entire  posterior  wall  of  the 
bladder  has  been  destroyed  its  repair  will  require  a  great  amount  of  skill  in 
plastic  surgery. 

During  the  past  few  years  since  the  introduction  of  very  extensive  opera- 
tions for  the  relief  of  carcinoma  of  the  cervix  uteri  in  connection  with 
vaginal  hysterectomy  we  have  encountered  a  number  of  patients  with  post- 
operative vesico-vaginal  fistula.  Usually  these  will  heal  after  the  operation 
described  above,  but.  occasionally  such  a  case  fails  to  heal  completely  after  sev- 
eral operations.  In  such  instances  it  is  best  to  open  the  abdominal  cavity  by 
a  low,  middle  incision,  separate  the  bladder  wall  from  the  scar  tissue,  being 
careful  not  to  injure  the  ureters  which  ma.y  have  been  drawn  toward  the 
median  line  by  cicatricial  contraction.  When  the  fistula  has  been  exposed  an 
area  with  a  diameter  of  two  to  four  cm.  is  denuded  and  the  fistula  is  closed  by 
folding  in  the  edges  of  the  bladder  with  three  rows  of  fine,  chromic  catgut 
sutures.  The  peritoneal  cavity  is  drained  through  the  vaginal  opening  by 
means  of  a  strand  of  gauze.  The  abdominal  cavity  is  closed  and  a  retention 
catheter  is  placed  in  the  bladder.  The  patient  receives  a  glass  of  distilled 
water  and  five  drops  of  dilute  aromatic  sulphuric  acid  every  one  to  two 
hours  to  prevent  the  formation  of  phosphates  in  the  bladder  or  the  retention 
catheter,  which  is  removed  about  the  tenth  day.  The  results  are  very  satis- 
factory, 

RECTO-VAGINAL  FISTULA 

This  condition  is  produced  either  by  the  opening  of  an  abscess  in  the  recto- 
vaginal septum  into  both  the  vagina  and  the  rectum  simultaneovisly,  or  by  the 
causes  which  have  been  mentioned  in  connection  with  vesico-vaginal  fistula. 
The  operation  for  its  relief  is  virtually  the  same  as  that  for  vesico-vaginal 
fistula,  with  the  addition  of  a  very  thorough  dilatation  of  the  sphincter  ani 
muscles  so  as  to  prevent  pressure  of  the  wound  from  the  side  of  the  rectum 
due  to  the  retention  of  fecal  material  on  account  of  a  tightly  constricted 
sphincter.    The  after-treatment  in  these  cases  is  the  same  as  that  just  described. 

CYSTS  OF  BARTHOLIN'S  GLANDS 

The  occlusion  of  the  ducts  of  Bartholin's  glands,  causing  cysts,  is  of  rather 
common  occurrence,  and  the  result  of  such  occlusion  is  the  same  as  of  the 
ducts  of  other  glands.  An  accumulation  of  the  mucus  secreted  by  the  gland 
occurs  within  the  ducts,  causing  a  distension  which  may  increase  to  such  an 
extent  as  to  give  rise  to  great  inconvenience  and  sometimes  to  pain.  The  loca- 
tion of  these  cysts  makes  their  infection  quite  likely,  and  consequently  sup- 
purating cysts  of  the  glands  of  Bartholin  is  not  an  uncommon  complication. 
This  is  especially  true  of  patients  who  have  suflPered  from  gonorrheal  infection. 
These  suppurating  cysts  may  open  spontaneously,  and  this  may  result  in  a 
spontaneous  cure  or  in  the  formation  of  a  fistula  or  recurrent  abscesses. 

Treatment.  The  treatment  may  consist  in  a  simple  puncture  of  the  cyst, 
but  this  will  usually  result  only  in  temporary  benefit,  and  is  consequently 
unjustifiable,  except  where  the  patient  must  have  immediate  relief  and  cannot 
possibly  subject  herself  to  a  radical  operation,  consisting  in  the  excision  of 
the  entire  cyst.  For  permanent  relief  an  incision  is  made  over  the  most  promi- 
nent portion  of  the  cyst,  which  is  then  dissected  out  from  the  surrounding 
tissues.  With  care  it  is  possible  to  obtain  the  line  of  cleavage  between  the 
cyst  wall  and  the  surrounding  tissues,  and  with  a  careful  dissection  the  entire 
tumor  can  usually  be  excised  without  rupture.     The  space  occupied  by  the 


SURGERY  OF  THE  FEMALE  PELVIS  659 

cyst  is  then  closed  by  means  of  a  few  buried  sutures  of  catgut  and  a  row  of 
sutures  uniting  the  mucous  membrane,  and  the  ordinary  dressing  applied. 

DYSMENORRHEA  DUE  TO  ATRESIA  OF  THE  CERVIX 

In  by  far  the  greater  number  of  patients  suffering  from  dysmenorrhea 
the  cause  lies  in  the  results  of  inflammatory  conditions  above  the  uterus.  In 
considering  appendicitis  this  subject  was  discussed,  and  again  in  speaking 
of  pyosalpinx,  but  there  is  a  certain  number  of  cases  in  which  none  of  the 
inflammatory  conditions  affecting  the  tubes  and  ovaries  are  present  and  in 
which  the  cause  of  the  dysmenorrhea  lies  in  an  atresia  of  the  cervix,  or  in 
a  mechanical  obstruction  due  to  a  short  bend  of  the  body  of  the  uterus  upon 
the  cervix,  or  in  an  inflammatory  condition  of  the  mucous  lining  of  the  uterus 
and  cervix.  In  these  patients  the  trouble  may  be  relieved  by  thorough  dila- 
tation of  the  cervix,  repeated  a  number  of  times.  The  dilatation  may  best  be 
started  by  inserting  ordinary  male  urethral  steel  sounds,  beginning  with  a 
size  sufficiently  small  to  enter  the  contracted  cervix  and  increasing  gradually 
until  the  largest  size  is  reached ;  then  introducing  a  uterine  dilator  and 
stretching  the  cervix  as  much  as  it  will  bear  without  tearing.  The  dilator 
should  be  left  in  position  under  tension,  then  relaxed,  then  dilated  again — 
and  this  repeated  many  times  until  the  canal  remains  comparatively  wide 
open  after  the  dilator  has  been  removed.  If  there  is  a  sharp  angle  between 
the  cervix  and  the  uterus  it  is  well  to  dilate  the  cervix  as  much  as  possible 
without  causing  any  laceration,  and  then  insert  a  tenotome  and  transversely 
cut  the  ridge  opposite  the  junction  between  the  body  of  the  uterus  and  the 
cervix.  In  case  there  has  been  an  endometritis  which  has  resulted  in  the 
formation  of  granulation  tissue  within  the  uterus  and  the  cervical  canal 
this  should  be  thoroughly  curetted  away  with  a  moderately  blunt  curette 
and  then  sponged  with  aseptic  gauze.  The  uterine  cavity  should  afterwards 
be  tamponed  with  a  piece  of  aseptic  gauze  moistened  with  ninety-five  per 
cent,  solution  of  carbolic  acid.  This  should  be  left  in  place  from  two  to  five 
minutes  and  then  withdrawn.  Then  the  cavity  should  be  tamponed  with 
a  piece  of  gauze  saturated  with  strong  alcohol.  After  this  has  been  removed 
a  piece  of  iodoform  gauze  may  be  carried  up  into  the  uterus  in  order  to 
serve  as  a  capillary  drain.  More  recently  we  have  invariably  tamponed 
the  uterus  with  gauze  saturated  with  Beck's  bismuth  paste.  This  tampon 
is  left  in  position  for  from  two  to  three  days. 

After-treatment.  The  patient  should  be  kept  in  bed  for  from  one  to  two 
weeks  and  receive  from  three  to  six  large,  hot  douches  every  day,  in  order 
to  relieve  the  congestion  resulting  from  the  operation.  During  the  subsequent 
menstrual  periods  the  patient  should  receive  a  mild  uterine  sedative  during 
each  period  for  a  number  of  months.  Patients  suffering  from  this  condition 
are  likely  to  expect  pain,  and  unless  some  sedative  is  given  a  slight  amount 
of  pain  may  be  exaggerated  by  their  nervous  condition  into  a  serious  degree 
of  suffering.  On  the  contrary,  if  a  uterine  sedative  is  given,  the  patient 
will  be  entirely  free  from  distress  and  consequently  soon  cease  looking  for 
pain  during  these  periods. 

The  prognosis  will  depend  upon  the  cause  of  the  dysmenorrhea.  If  the 
cause  was  entirely  in  the  cervix  or  in  the  uterus  a  very  satisfactory  result 
may  be  expected.  If,  however,  it  was  in  the  tubes  and  ovaries,  then  the  result 
will  be  entirely  negative. 


PART  X 

SURGERY  OF  THE  EXTREMITIES 


OPERATIONS  FOR  THE  RELIEF  OF  FRACTURES 

The  scope  of  this  work  does  not  comprehend  the  treatment  of  fractures, 
except  those  in  which  operative  interference  is  indicated.  At  the  outset  we 
wish  to  state  that  operative  intervention  is  not  indicated  in  any  form  of  frac- 
ture unless  the  operator  absolutely  controls  the  conditions  of  asepsis  during 
the  operation,  because  an  infection  is  so  much  more  serious  than  the  fracture 
itself  that  if  this  cannot  be  thoroughly  eliminated  an  incisional  operation  is, 
of  course,  not  indicated. 

Anatomic  and  functional  results.  In  the  past  it  has  generally  been  accepted 
that  shortenings  of  from  one-half  to  one  inch  in  fractures  of  the  femur,  and  in 
oblique  fractures  of  the  tibia  and  fibula,  are  satisfactory  results.  To-day,  not 
only  are  surgeons  striving  to  obtain  better  results  but  the  public  demands 
better  consequences,  both  as  to  function  and  deformity  following  the  treat- 
ment of  a  broken  bone.  The  X-ray  undoubtedly  has  had  a  great  deal  to  do 
with  bringing  this  about.  It  must  not  be  forgotten  that  the  finality  of  our 
treatment,  whether  operative  or  not,  is  likely  to  be  tested  by  radiography,  and 
if  the  fragments  are  shown  not  to  be  in  accurate  apposition,  the  patient  is 
likely  to  think  that  the  surgeon  has  not  exercised  proper  skill  in  the  manage- 
ment of  his  case.  This  impression  is  especially  apt  to  be  convej^'ed  if  there  is 
some  loss  of  function  besides  the  anatomic  defect.  As  to  the  ultimate  func- 
tional result,  the  shortening  is  not  of  so  much  importance  as  the  rotary  or 
angular  deformity  which  usually  accompanies  the  shortening  in  fractures  of 
the  femur. 

In  deciding  as  to  whether  any  particular  fracture  should  be  operated  upon, 
or  should  be  treated  by  splints,  plaster-of-Paris  or  extension,  etc.,  the  impor- 
tance or  not  of  restoring  the  bones  to  their  normal  form  should  be  the  first 
consideration. 

In  any  given  case  in  which,  from  the  location  of  the  fracture,  or  after  con- 
sidering the  occupation  of  the  patient,  it  seems  important  to  restore  the  bone 
to  its  normal  form,  the  next  important  thing  to  consider  is,  how  can  we  secure 
an  accurate  apposition  of  the  fractured  ends  with  good  alignment,  and  be  able 
to  hold  them  in  this  position  with  a  reasonable  degree  of  certainty.  In  a  large 
proportion  of  simple  fractures,  the  surgeon  may,  after  careful  examination, 
feel  fairly  sure  that  he  can  secure  the  above  conditions  by  some  of  the  ordinary 
means  at  his  command;  and  in  such  cases  there  certainly  is  no  indication  for 
operative  treatment.  On  the  other  hand,  there  are  many  fractures  in  which, 
after  careful  examination,  the  surgeon  feels  that  he  cannot  hold  the  fragments 
in  accurate  apposition  with  any  degree  of  certainty  by  the  ordinary  methods 
of  treatment.  In  this  class  of  cases,  it  is  well  to  consider  the  open  method  of 
exposing  the  fragments  by  a  formal  dissection  and  securing  an  accurate  apposi- 
tion by  dovetailing  the  parts  into  their  normal  position,  which  will  do  away 
with  all  rotary  displacement  and  be  the  first  step  toward  a  proper  alignment. 

661 


662 


SURGERY  OF  THE  EXTREMITIES 


i 


Malunited  fracture  of  upper  third 
of  femur  with  a  plate  and  eight 
screws.  Picture  eight  months  after 
operation. 


Fracture  of  surgical  neck  of  humerus  nailed  three 
weeks  after  accident.  Picture  two  weeks  after 
operation. 


SURGERY  OF  THE  EXTREMITIES 


663 


Old  ununited  fracture  of  lower  third 
of  humerus,  three  years'  duration.  Pic- 
ture three  and  one-half  years  after 
operation. 


Oblique  fracture 
transverse  of  fibula, 
after  operation. 


middle    of    tibia    and 
Picture  seven  mouths 


664:  SURGERY  OF  THE  EXTREMITIES 

Operative  devices  to  secure  fixation.  There  are  several  methods  of  open 
operations  at  our  command,  such  as  wiring  tlie  ends  of  the  bone,  tlie  introduc- 
tion of  iniermedullary  bone  grafts,  or  bone  inlays,  the  use  of  the  Farkhiirs 
screws  and  clamp,  the  use  of  the  steel  nails  or  bone  or  ivory  pegs,  and  the  use 
of  the  Lane  plates.  Of  the  various  methods  m  foreign  material  used  as  a  means 
of  tixation,  the  Lane  plates  seem  to  be  the  best  method  by  which  to  actually 
hold  the  fragments  in  all  directions  and  at  the  same  time  leave  no  communi- 
cation with  the  skin  to  predispose  to  infection.  The  Lane  method  consists 
of  cutting  down  upon  a  fracture,  bringing  the  broken  bones  into  accurate 
apposition,  and  fixing  in  this  position  by  the  application  of  high-grade,  cold- 
rolled,  steel  plates.  The  plates  are  provided  with  from  two  to  ten  reinforced 
screw  holes,  arranged  in  series  of  one,  two,  three,  four  and  live  at  each  end, 
according  to  the  size  and  strength  of  the  plate.  The  plate  is  held  in  place  by 
the  introduction  of  steel  screws  which  are  threaded  up  to  their  heads. 

One  must  remember  that  there  is  a  varying  degree  of  risk  connected  with 
this  operation,  and  this  danger  must  be  taken  into  consideration.  The  chief 
difficulty  is,  that  when  a  foreign  body  is  left  in  the  tissues,  the  surgeon  must  be 
inhnitely  more  carefitl  of  his  asepsis  than  in  ordinary  surgical  procedures.  A 
laparotomj'  is  a  simple  matter  compared  to  the  open  treatment  of  a  fracture. 
The  peritoneum  is  our  friend  and  will  take  care  of  a  great  many  microbes  if 
we  treat  it  kindly,  but  bones  and  the  tissues  about  them  will  not.  It  is  because 
of  insufficient,  aseptic  precautions  that  we  hear  of  rarefying  osteitis  taking 
place  about  wire  and  screws.  It  is  for  this  same  reason  that  sinuses  and  the 
other  more  serious  complications  develop  in  these  wounds  after  operation. 

Unfortunately  many  bad  restilts  have  followed  the  use  of  steel  plates,  and 
as  a  result,  the  Lane  method  has  suffered  from  much  unjttst  criticism.  There 
are  many  cases  which  were  plated  two  years  ago  who  are  suffering  today 
from  complications  that  arose  at  the  time  of,  or  following,  the  operation, 
wherein  there  is  a  necrosis  of  the  ends  of  the  bone  with  a  consequent  non- 
union, or  the  patient  still  has  an  infected  bone  with  a  chronic  osteom.yelitis, 
or  has  a  stiiiened,  greatly-impaired  extremity  as  a  result  of  the  wide-spread, 
purulent  inhltration  of  the  soft  parts.  Even  after  seeing  these  bad  results  one 
should  not  condemn  the  method  until  he  has  stopped  to  consider  why  these 
various  complications  followed  the  plating. 

It  is  evident  that  Mr.  Lane  and  several  other  surgeons  have  demonstrated 
beyond  a  doubt  that  foreign  bodies,  such  as  steel  plates,  can  be  fastened  to 
bones  and  left  in  place  permanently  without  causing  any  irritation  whatso- 
ever, and  that  the  majority  of  the  various  complications  that  do  follow  their 
use  are  caused  by  the  introduction  of  infection  at  the  time  of  operation. 

During  the  past  eight  years  it  has  been  the  practice  of  the  authors  to  operate 
upon  all  simple  fractures  of  long  bones  in  which  we  were  unable  to  restore  the 
normal  relationship  of  the  fragments  by  ordinary  means,  and  in  laboring 
people  in  whom  it  was  important  that  their  mechanics  should  not  be  impaired. 
In  the  majority  of  these  cases  we  have  used  the  method  of  Mr.  Lane,  of  London, 
which  consists,  as  before  stated,  in  the  application  of  steel  plates  to  keep  the 
fragments  in  place.  AVe  have  found  that  this  method  of  treatment  in  simple 
fractures  possesses  all  of  the  advantages  to  the  patient,  claimed  for  it  by 
Mr.  Lane,  which  are  as  follows: 

1.  The  patient  is  at  once  relieved  of  the  pain  of  any  movement  of  the 
fragments  upon  one  another. 

2.  He  is  freed  from  the  tension  and  discomfort  due  to  the  extensive  ex- 
travasation of  blood  between  and  into  the  tissues. 


SURGERY  OF  THE  EXTREMITIES 


665 


Ununited  fracture  ulna  and  radius,  seven 
months'  duration.  Picture  two  years  after 
operation,  apparent  non-union  of  ulna,  but  per- 
fect functional  result. 


666 


SURGERY  OF  THE  EXTREMITIES 


Transverse   fracture   of   lower   end   of   femur. 
lowing  plate. 


See   fol-  Same    case    as    preceding    after    applicati 

of  one  steel  plate. 


SURGERY  OF  THE  EXTREMITIES  667 

3.  It  shortens  the  duration  of  the  period  during  which  he  is  incapacitated 
from  work,  since  union  is  practically  by  first  intention,  and  consequently  very 
rapid  and  perfect. 

4.  Lastly,  and  by  far  the  most  important,  they  leave  the  skeletal  mechanics 
in  the  condition  in  which  they  were  before. the  sustained  injury. 

This  treatment  is  especially  indicated  in  fractures  of  the  shaft  of  the 
humerus  and  the  femur,  for  in  the  majority  of  cases  one  cannot  hold  the  fra^a:- 
ments  in  accurate  apposition  with  any  degree  of  certainty  without  operative 
measures. 

This  method  of  treatment  should  not  be  used  except  in  a  well-regulated 
hospital  where  the  surgeon  can  be  absolutely  certain  that  every  detail  of  the 
operation  will  be  carried  on  in  an  aseptic  njanner. 

Time  of  operation.  In  the  majority  of  simple  fractures  it  has  been  our 
practice  to  operate  immediately  if  the  patient  comes  under  our  care  during  the 
first  day  or  two.  The  bones  are  much  easier  to  adjust  at  this  time  before  mus- 
cular contraction  has  taken  place.  Occasionally  when  a  fracture  comes  under 
observation  on  the  third  or  fourth  day,  and  there  is  considerable  swelling  of 
the  tissues,  we  prefer  to  wait  three  or  four  days  longer  until  the  circulation  in 
the  surrounding  tissues  has  improved.  So  far  as  we  have  been  able  to  observe 
the  cases  operated  upon  the  first  day  have  done  just  as  well  as  those  operated 
after  a  week  or  ten  days  have  elapsed. 

A  rigid  technique  is  necessary.  1.  The  skin  in  the  region  of  the  fracture  is 
very  thoroughly  disinfected,  and  an  incision  is  made  through  it  and  superficial 
fascia  at  a  point  from  which  the  fragments  may  be  reached  with  a  minimum 
damage  to  the  soft  parts.  The  skin  in  the  field  of  operation  should  now  be 
excluded  from  the  wound  by  attaching  sterile  gauze  pads  to  the  divided  margin 
of  the  skin  by  means  of  forceps  devised  for  this  purpose. 

2.  It  is  important  that  asepsis  be  carried  out  to  the  most  extreme  degree, 
and  this  can  be  done  only  by  doing  the  entire  operation  with  instruments  and 
not  allowing  the  operator's  gloved  fingers  to  come  in  contact  with  any  portion 
of  the  wound.  Also  it  is  important  that  no  instrument  or  sponge  come  in  con- 
tact Avith  any  other  object  after  coming  from  the  sterilizer.  This  can  be  accom- 
plished by  placing  all  of  the  instruments  to  be  used  in  the  operation  in  the 
tray  in  which  the  instruments  are  sterilized,  and  then  bringing  the  tray 
directly  from  the  sterilizer  to  the  instrument  table,  and  using  the  instruments 
directly  from  this  tray. 

The  sponges  to  be  used  are  taken  by  a  pair  of  forceps  from  a  package  of 
sponges  which  has  not  been  opened  since  coming  from  the  sterilizer.  Thus  the 
sponges  and  the  instruments  come  direct  to  the  operator  without  passing 
through  any  other  hands. 

3.  If  blood  clots  are  present  they  should  be  removed  from  the  wound. 

4.  All  hemorrhage  should  be  controlled  by  applying  large  hemostatic 
forceps  so  that  by  the  time  the  operation  is  completed  the  forceps  can  be 
removed  without  applying  any  ligatures. 

5.  Accurate  apposition  of  the  fragments  should  be  secured,  and  this  can 
be  easily  accomplished  by  grasping  each  fragment  with  a  pair  of  heavy,  bone- 
holding  forceps  devised  especially  for  this  purpose. 

6.  The  periosteum  should  not  be  injured,  and  should  be  left  in  its  normal 
position,  the  plate  being  applied  over  the  periosteum. 

7.  The  size  of  the  plate  to  be  used  should  be  selected  according  to  the 
strain  that  is  likely  to  be  placed  upon  it.     One  or  more  plates  are  applied  to 


668 


SURGERY  OF  THE  EXTREMITIES 


Fracture  of  neck  of  femur  through  which  has  been  driven  two  nails. 


SURGERY  OF  THE  EXTREMITIES 


669 


Oblique    fracture   of   femur   extending   from   greater  to   lesser    trochanter.      Picture    eighteen 

months  after  operation. 


670 


SURGERY  OF  THE  EXTREMITIES 


the  bone,  depending  upon  the  degree  of  security  desired.  It  is  well  to  plate 
securely  in  the  region  of  the  knee-joint  so  that  the  knee  may  be  manipulated 
during  convalescence  without  endangering  the  holding  of  the  plates.  A  plate 
should  never  be  placed  subcutaneously  if  it  is  possible  to  cover  it  up  with 
muscle,  but  when  it  is  necessary  to  do  so  the  incision  should  be  made  a  con- 
siderable distance  from  the  location  of  the  plate, 

8.     A  hole  should  be  drilled  for  introducing  the  screws  and  it  is  important 


X-ray  of  an  ununited  fracture  of  the  humerus  of  ten  years'  standing.     Elbow  is   at   angle 
of  90°  and  the  lower  fragment  of  humerus  is  at  right  angle  to  shaft  of  humerus. 


that  the  size  of  the  hole  be  just  a  little  smaller  than  the  screw  so  that  the  screw 
will  fit  tightly.  Enough  screws  should  be  introduced  to  hold  the  plate  very 
firmly. 

The  wound  is  closed  by  allowing  the  muscles  to  fall  together  and  simply 
suturing  the  fascia  and  skin  and  not  introducing  any  catgut  deep  into  the 
wound  in  the  region  of  the  plates. 

It  is  important  to  secure  a  very  accurate  apposition  of  the  skin  either  by 
horsehair  or  metal  clips,  so  that  there  will  be  perfect  union  by  first  intention, 
doing  away  with  any  possibility  of  infection  coming  from  the  skin.  Drainage 
should  never  be  used. 


SURGERY  OF  THE  EXTREMITIES 


671 


9.  A  plain,  sterile  dressing  should  be  applied  and  the  extremity  should  be 
immobilized,  either  by  splints  or  plaster-of-Paris,  so  that  unnecessary  strain 
will  not  be  placed  upon  the  plates. 

Immobilization  should  be  continued  the  same  length  of  time  as  if  the  plates 
had  not  been  used. 

Removal  of  plates.  If  a  plate  has  been  placed  subcutaneously  and  causes 
anv  annoyance  it  should  be  removed  as  soon  as  union  has  taken  place.    Plates 


yame  case  as  shown  in  preceding  illustration,  showing  Lane  plate  in  place. 


placed  so  that  they  are  covered  with  muscle  will  seldom  have  to  be  removed  if 
they  have  been  introduced  absolutely  aseptic.  As  surgeons  in  general  increase 
their  technique,  both  as  to  manual  dexterity  and  cleanliness,  fewer  plates  will 
have  to  be  removed. 

A  plate  or  screw  placed  across  or  through  the  epiphyseal  line  should  be 
removed  after  union  has  taken  place. 

In  over  two  hundred  cases  of  simple  fractures  operated  during  the  past 
eight  years,  the  authors  have  found  it  necessary  to  remove  plates  from  eight 
per  cent,  of  cases. 


672 


SURGERY  OF  THE  EXTREMITIES 


Old  ununited  fracture  of  tibia  and  fibula  in  boy  eight 
years  of  age. 


Same  case  as  shown  in  ac- 
conipanying  illustration.  Tibia 
held  in  place  by  two  metal 
plates.  Picture  six  months 
after  operation. 


SURGERY  OF  THE  EXTREMITIES 


673 


Ununited  fracture  of  lower  end 
of  tibia  and  fibula.  Two  metal 
plates  at  right  angles  to  each 
other  on  the  tibia.  Picture  six 
months  after  operation. 


Oblique  fracture  upper  third  of  tilua. 
Transverse  tracture  fibula.  One  plate 
on  tibia.  Picture  seven  months  after 
operation. 


674 


SURGERY  OF  THE  EXTREMITIES 


SURGERY  OF  THE  EXTREMITIES 


675 


ir  fractured  four  weeks  before  admission.     Age   of 
patient  seven  years. 


Same  case  seven  months  after  jilate 
was  applied. 


1 


676  SURGERY  OF  THE  EXTREMITIES 

FIXATION  OF  FRACTURES  BY  BONE  GRAFT 


At  the  present  time  many  surgeons  are  giving  up  the  use  of  foreign  ma- 
terial as  a  means  of  fixation  for  fractures  and  substituting  the  autogenous 
bone  graft.  This  has  the  one  definite  advantage  of  not  placing  a  foreign 
body  in  the  tissues.  In  the  majority  of  fractures  Avhich  require  operation,'' a 
bone  graft  can  be  easily  introduced  and  will  give  sufficient  fixation  to  ensure 
an  excellent  result.  On  the  other  hand,  one  often  meets  with  fractures  of 
the  tibia  and  femur,  especially,  in  which  a  steel  plate  will  give  a  better  fixa- 
tion and  can  be  introduced  with  greater  ease  than  a  bone  graft.  In  such 
cases  the  use  of  the  plate  should  be  the  method  of  choice.  There  are  two 
methods  of  fixation  in  using  the  bone  graft,  namely,  the  intra-medullary 
graft  and  the  bone  inlay  method.  In  fractures  in  which  there  is  no  loss  of 
bone,  the  bone  inlay  method  of  Albee  is  preferable  in  most  cases. 

Technique  of  inlay  graft.  The  bone  for  the  inlay  may  be  taken  from 
the  fragments  of  the  broken  bone,  or  from  the  tibia.  In  fresh  fractures  the 
graft  can  usually  be  taken  from  the  fragments,  as  there  has  been  no  impair- 
ment of  the  osteogenetic  function  of  the  bone.  In  old  fractures  it  is  usually 
preferable  to  secure  the  graft  from  the  tibia,  as  a  marked  rarefaction  of 
the  fragments  may  have  taken  place,  especially  in  the  lower  fragment.  For 
this  reason,  if  the  graft  is  taken  from  the  fragments,  it  should  be  taken  from 
the  upper  fragment  and  slid  down  into  the  lower,  because  more  rarefaction  is 
likely  to  have  taken  place  in  the  distal  than  in  the  proximal  fragment. 

The  skin  incision  should  be  a  liberal  one,  in  order  that  the  operation  may 
be  done  with  as  little  trauma  to  the  bone  and  surrounding  tissues  as  is 
possible.  Trauma  not  only  predisposes  to  infection,  but  may  have  an  in- 
hibitory influence  to  cellular  proliferation.  If  the  incision  is  short,  trauma 
may  arise  from  the  strong  retraction  of  the  muscles  which  will  be  necessary 
in  carrying  out  the  operation.  The  same  degree  of  asepsis,  as  previously 
described  in  the  use  of  steel  plates,  should  be  carried  out,  as  a  resulting  in- 
fection of  any  of  the  involved  tissues  may  interfere  with  a  successful 
result.  After  the  long  skin  incision  has  been  made,  the  dissection  is  carried 
down  thro-ugh  the  fascia  and  muscles  to  the  bone,  securing  a  good  exposure 
of  the  fragments.  All  soft  tissues  from  between  the  fragments  should  be 
removed  and  the  ends  of  the  bone  placed  so  as  to  restore  as  nearly  as  possible 
the  normal  contour  of  the  bone. 

If  the  inlay  graft  is  to  be  taken  from  the  tibia,  the  periosteum  on  the 
fragments  is  incised  longitudinally  and  peeled  back  to  either  side,  in  the  form 
of  flaps,  from  the  bone  which  is  to  be  removed  for  the  purpose  of  forming  a 
gutter  to  receive  the  inlay.  If  the  inlay  is  to  be  taken  from  the  proximal 
fragment,  the  periosteum  from  this  fragment  should  not  be  disturbed,  as  it 
is  better  for  the  graft  to  include  the  periosteum  as  well  as  the  endosteum 
and  marroAV  substance. 

In  cutting  the  inlay,  it  is  essential  that  it  be  of  uniform  width  and  the  size 
be  such  as  to  fit  accurately  into  the  gutter  in  the  bone  where  it  is  to  be 
placed.  The  graft  is  started  by  taking  a  twin  saw,  adjusted  to  proper  width, 
and  cutting  through  the  periosteum  and  about  one-twentieth  of  an  inch  into 
the  bone,  then  outlining  a  graft  of  uniform  width  throughout  its  whole  length. 
A  single  saw  is  now  used  continuing  these  two  parallel  cuts  through  into  the 
medullary  cavity.  The  saw  is  held  at  such  an  angle  as  to  cause  the  cuts  to 
converge  in  approaching  the  medullary  cavity.  The  saw  should  be  held  at 
the  same  angle  while  cutting  the  gutter  in  the  fragments  which  are  to  receive 
the  graft.  The  ends  of  the  graft  are  freed  with  transverse  cuts  made  by  a 
chisel.  The  object  of  the  Avedge-shaped  graft  and  gutter  is  to  prevent  the 
graft  from  slipping  into  the  medullary  canal  when  it  is  in  place.    If  the  graft 


SURGERY  OF  THE  EXTREMITIES  677 

has  been  cut  properly,  it  will  sink  slightly  below  the  edges  of  the  gutter  when 
it  is  in  place.  Two  holes  are  now  drilled,  obliquely  through  each  margin  of 
the  gutter  in  both  fragments.  The  inlay  is  now  fastened  securely  in  place 
by  passing  kangaroo  tendon  through  the  drilled  holes  and  tying  over  the 
graft,  or  by  inserting  an  autogenous  dowel  peg  in  each  drill  hole.  The  wound 
is  closed  without  drainage.  The  fractured  extremity  should  be  immobilized 
completely  with  plaster-of-Paris,  or  other  suitable  dressing.  The  period  of 
immobilization  should  be  at  least  twelve  weeks. 

UNUNITED  FRACTURES 

Local  or  constitutional  causes.  In  considering  the  treatment  of  delayed 
union,  or  non-union, ,  of  fractures,  it  is  important  to  determine  whether  the 
cause  is  constitutional  or  local.  Although  many  general  conditions  have  been 
attributed  as  the  cause  of  failure  of  union,  it  is  very  probable  that  in  most 
instances  the  fault  is  some  local  trouble.  Constitutional  disturbances,  such  as 
the  presence  of  infectious  diseases,  pregnancy  and  lactation,  prolonged  illness, 
central  nerve  lesions,  anemia  or  any  exhausting  condition,  are  of  importance 
probably  from  their  inlluence  in  depressing  the  general  cellular  activity.  It  is 
very  likely  that  the  interference  with  union  in  most  cases  is  due  to  one  of  sev- 
eral local  conditions,  such  as  over-riding  of  the  fragments,  a  separation  of  the 
fragments  by  the  interposition  of  fascia,  muscle  or  cicatricial  tissue,  or  to 
disturbances  of  the  blood  or  nerve  supply. 

In  nearh^  all  of  our  cases  we  have  found  that  the  ends  of  the  fragments 
were  separated  by  some  soft  tissue,  and  that  this  happens  usually  in  patients 
who  have  sustained  a  violent  injury  so  that  the  ends  of  the  bones  have  been 
forced  past  each  other  with  great  power. 

Bone  is  a  special  tissue  and  there  will  be  no  callous  formation  unless  one 
fragment  actually  comes  in  contact  with  the  other  in  some  manner.  Therefore, 
in  order  to  secure  union  in  any  fracture  it  is  essential  that  the  bony  tissue  of 
one  fragment  actually  comes  in  contact  with  the  bony  tissue  of  the  other  frac- 
tured end. 

Union  can  be  secured  in  the  majority  of  cases  by  simply  cutting  down  upon 
the  fragments,  removing  all  soft  tissue  between  the  fractured  surfaces,  freshen- 
ing the  ends  and  securing  accurate  apposition  by  fastening  the  pieces  of  bone 
together  by  the  application  of  two  heavy  steel  plates  held  in  place  by  screws. 
In  cases  of  non-union  one  should  be  especially  careful  to  see  that  the  bone  is 
well  plated. 

The  operation  of  choice,  however,  is  the  use  of  an  intra-medullary  splint  of 
bone,  as  advised  by  Murphy,  or  the  bone  inlay  method  of  Albee,  as  previously 
described.  The  latter  method  is  especially  indicated  when  one  meets  with  a 
case  of  non-union  in  which  the  fragments  are  in  accurate  apposition  but  the 
ends  of  the  bone  are  smooth  and  extremely  hard,  with  no  attempt  whatever  at 
osteogenesis  taking  place.  This  piece  of  bone  gives  a  scaffolding  through 
which  the  Haversian  vessels  travel  through  the  Haversian  canals  of  the  trans- 
planted bone.  The  transplanted  bone  is  eventually  absorbed  and  replaced  by 
new  bone. 

Clinical  history  of  a  case  in  point.  Patient  forty-five  years  of  age,  a  machinist  by 
trade.  Family  history  very  good.  Personal  history  good,  in  fact  patient  had  never  been 
sick  until  time  of  accident,  several  years  ago,  when  he  vras  kicked  by  a  horse  on  the  right 
arm,  wnich  produced  a  compound,  comminuted  fracture  of  the  humerus  at  junction  of  lower 
and  middle  third.  Wound  became  infected  and  patient  remained  in  the  hospital  for  a  period 
of  twenty-two  months,  during  which  time  he  underwent  four  surgical  operations,  some  pieces 
of  bone  being  removed  each   time. 

At  the  time  of  leaving  hospital,  wound  was  completely  healed,  but  there  was  no  union 
of  the  two  fragments  of  the  humerus.     One  year  later  patient  was   operated  upon  for  the 


678  SURGERY  OF  THE  EXTREMITIES 

non-union.  The  ends  of  the  bone  were  freshened  and  fastened  together  by  means  of  silvei 
wire.  Again  the  bone  did  not  unite  and  the  wire  had  to  be  removed  a  few  months  latei 
because  of  irritation.  Two  years  later  a  second  operation  was  performed,  the  ends  of  tli< 
fraginents  freshened  and  again  fastened  with  silver  wire,  the  result  being  the  same  as  before 
Two  more  attempts  were  made  in  like  manner  to  secure  union,  but  the  result  was  the  sam( 
each  time.  Later  he  received  a  bullet  wound  in  left  thigh.  The  bullet  was  not  removed  anc 
has  never  caused  any  trouble.  During  past  two  years  patient  troubled  some  with  belchinj 
of  gas  and  some  distress  in  epigastrium  after  eating,  otherwise  well  until  up  to  the  preseni 
time.  Patient  comes  complaining  of  a  false  joint  in  right  arm  at  a  point  about  three  inches 
above  the  elbow. 

Examination.  Patient  is  well  nourished,  tongue  coated,  appetite  good,  bowels  regular 
chest   is  negative,   abdomen   negative. 

Ann.  Distance  from  right  acromion  process  to  olecranon  process  is  13 1/^  inches.  Dis 
tance  from  left  acromion  process  to  left  olecranon  process  is  17  inches.  Considerable  atrophy 
of  muscles  of  right  arm,  but  muscles  of  right  forearm  are  about  normal.  Patient  has  gooc 
use  of  forearm,  the  false  joint  in  the  humerus  acting  as  the  elbow- joint.  The  false  joint  ir 
the  humerus  is  ten  inches  distant  from  the  right  acromion  process.  The  lower  fragment  oJ 
the  humerus  which  was  about  81/2  inches  long  remained  at  right  angles  to  the  bones  of  th( 
forearm.  By  grasping  this  fragment  firmly  and  moving  the  forearm  it  was  found  that  ther( 
was  about  twenty  degrees  motion  in  the  elbow-jomt.  When  the  forearm  was  extended  th< 
lower  fragment  assumed  a  transverse  position  to  the  long  axis  of  the  humerus  as  showr 
in  the  plate. 

Technique.  Patient  was  anesthetized  and  an  incision  made  on  the  outei 
surface  of  right  arm  on  the  false  joint.  The  musculo-spiral  nerve  was  exposec 
early  in  the  dissection.  It  was  markedly  enlarged  and  imbedded  in  connective 
tissue  in  the  region  of  the  false  joint.  The  nerve  was  dissected  free  anc 
retracted.  All  of  the  connective  tissue  was  dissected  away,  the  ends  of  the  bont 
were  freshened  by  sawing  ofip  the  rounded  ends,  and  two  fragments  approxi 
mated  and  held  in  apposition  by  screwing  two  steel  plates  on  the  humerus 
This  was  accomplished  with  considerable  difficulty  on  account  of  the  shortness 
of  the  lower  fragment  and  the  limited  motion  in  the  elbow-joint.  It  was  neceS' 
sary  to  place  the  forearm  at  right  angles  to  the  arm  in  order  to  bring  th( 
fragments  in  juxtaposition,  making  it  rather  difficult  to  apply  the  plates  to  th( 
short  lower  fragment.  After  the  plates  were  applied,  the  wound  was  closec 
and  a  cast  applied  with  forearm  at  right  angles  to  arm. 

Cast  was  removed  at  end  of  twelve  weeks  at  which  time  the  bone  seemed 
to  be  very  firm.  The  arm  was  left  without  a  cast  and  was  examined  again  in  a 
week.  At  this  time  union  seemed  very  firm,  there  was  absolutely  no  pain  01 
tenderness  and  there  was  about  thirty  degrees  of  motion  in  the  elbow-joint 
A  report  tAvo  years  later  stated  there  was  union  of  bone  with  no  trouble  from 
plates. 

MALUNITED  FRACTURES 

In  badly  united  fractures  in  which  there  is  considerable  loss  of  function, 
operation  is  indicated.  This  class  of  cases  is  often  difficult  to  handle,  especially 
if  more  than  one  bone  is  involved  and  if  considerable  time  has  elapsed  since  the 
injury.  In  every  case  an  attempt  should  be  made  to  correct  the  shortening  as 
w^ell  as  the  alignment,  and  this  can  be  accomplished  completely,  or  nearly  so, 
in  every  instance.  In  case  of  a  femur  in  which  there  is  an  overlapping  of  from 
one  to  three  inches,  it  is  impossible  by  direct  pulling  to  stretch  the  muscles 
sufficiently  to  allow  the  ends  of  the  bone  to  come  in  apposition.  This,  how- 
ever, can  be  accomplished  very  easily  by  bending  the  thigh  upon  itself  so  that 
the  two  ends  of  the  bone  are  at  right  angles  to  each  other,  then  grasp  each 
fragment  with  a  pair  of  heavy  forceps  and  hold  the  ends  of  the  bone  against 
each  other  while  some  one  straightens  the  thigh.  This  gives  a  tremendous 
leverage  and  the  muscles  are  stretched  without  any  difficulty.  If  there  has 
been  no  recent  infection  to  form  connective  tissue  about  the  vessels  and  nerves, 


SUEGERY  OF  THE  EXTREMITIES  679 

there  will  be  no  danger  of  tearing  the  muscles,  vessels  or  nerves,  as  normall}^ 
they  will  stretch  any  reasonable  distance. 

In  each  case  of  fracture  before  open  operation  is  attempted  a  careful  history 
should  be  taken  and  a  search  made  to  determine  whether  or  not  there  exists 
any  constitutional  disturbance,  such  as  syphilis,  anemia,  hypothyroidism  or 
other  conditions  that  might  possibly  interfere  with  bony  union. 

Patients  suffering  from  such  disorders  are  poor  surgical  risks  and  should 
be  subject  to  appropriate  treatment  to  correct  these  diseases  before  operation 
is  performed. 

COMPOUND  FRACTURES 

In  compound  fractures  the  most  important  point  to  be  considered  is  the 
production  of  conditions  as  nearh^  as  possible  like  those  in  simple  fractures. 
These  conditions  may  be  secured  most  readily  by  laying  the  wound  open  suffi- 
ciently to  remove  the  extraneous  matter  Avhich  may  have  been  forced  into  it  at 
the  time  of  the  injury,  or  by  the  manipulations  which  occurred  before  the 
patient  reached  the  hands  of  the  surgeon.  After  the  wound  has  been  carefully 
disinfected  by  applying  strong  tincture  of  iodine,  without  using  any  soap  and 
water,  and  all  of  the  entirely  loose  fragments  removed,  those  which  have  some 
attachment  to  the  periosteum  being  carefully  adjusted,  the  fragments  should 
be  placed  in  as  nearly  a  normal  position  as  possible,  and  if  it  seems  likely  that 
this  position  can  be  maintained  by  the  use  of  external  splints,  then  it  seems 
proper  that  such  external  splints  be  applied.  If,  however,  it  is  clear  that  this 
position  of  the  fragments  cannot  be  maintained  then  the  same  may  be  sutured 
in  place  by  means  of  catgut  sutures. 

We  seldom  if  ever  introduce  a  Lane  plate  in  compound  fracture,  because  of 
the  possibility  of  a  septic  infection  following  the  introduction  of  a  foreign 
body  in  these  cases  is  so  great  that  we  prefer  taking  the  chances  of  having  the 
fragments  unite  in  a  bad  position  than  taking  the  risk  of  placing  screws  or 
wire  in  a  septic  wound.  After  a  compound  fracture  has  healed,  if  there  is 
much  deformity,  this  can  be  corrected  by  an  open  operation.  If  in  any  given 
case  of  compound  fracture  it  seems  wise  to  introduce  plates  in  order  to  bring 
the  fragments  in  contact  with  each  other,  it  is  well  to  pack  the  wound  wide 
open  and  then  remove  the  plate  as  soon  as  union  has  taken  place. 

FRACTURES  IN  CHILDREN 

Fractures  in  children  seldom  require  open  operation.  In  most  cases  the 
reduction  of  the  fragments  can  be  accomplished  without  much  difficulty.  Even 
though  one  cannot  secure  the  parts  in  accurate  apposition,  union  usually  takes 
place  rapidly,  and  any  deformity  that  follows  generally  undergoes  a  modelling 
process  and  has  a  tendency  to  disappear. 

FRACTURE  OF  THE  PATELLA 

If  the  surgeon  thoroughly  controls  the  situation  so  that  he  can  be  certain 
of  asepsis,  then  in  fracture  of  the  patella  we  believe  the  operative  method  is 
always  indicated,  as  with  it  the  patient  may  be  out  of  bed  in  less  than  one 
week,  he  may  walk  about  comfortably  in  three  weeks,  and  in  from  eight  to 
ten  weeks  he  should  be  able  to  follow  any  occupation  he  may  have  had  at  the 
time  of  injury,  while  without  such  operative  treatment  he  Avill  be  disabled  for 
many  months  at  best. 

An  illustrative  case.  A  man,  forty  years  of  age,  fell  upon  his  right  patella  and  fractured 
it.     He  had  it  treated  by  means  of  splints  and  strapping,  and  obtained  a  very  satisfactory 


680 


SURGERY  OF  THE  EXTREMITIES 


CC 


03 


SURGERY  OF  THE  EXTREMITIES 


681 


Another  view  of  the  same  case  with  plates  in  place 
three  and  one-half  years. 


682  SURGERY  OF  THE  EXTREMITIES 

result,  which  enabled  him,  at  the  end  of  six  months,  to  pursue  his  occujaation  of  book-keeper 
in  a  large  establishment ;  the  knee,  however,  never  became  thoroughly  strong,  and  the  patient 
could  not  take  long  walks  without  becoming  exhausted.  Two  years  later  he  fell  upon  the 
other  knee  and  fratured  the  patella  in  the  same  manner.  An  open  operation  was  at  once 
j^erformed  and  the  extremity  placed  in  a  plaster-of-Paris  cast.  At  the  end  of  one  week  the 
patient  was  allowed  to  be  out  of  bed.  At  the  end  of  three  weeks  he  was  able  to  resume 
work  in  the  office,  continuing,  however,  to  wear  a  cast.  At  the  end  of  eight  weeks  his  left 
leg  was  in  a  much  better  condition  than  his  right,  which  had  been  injured  two  and  one-half 
years  before. 

We  have  had  numerous  opportunities  of  making  similar  comparisons  in 
fractures  of  the  patella  taking  place  in  different  persons  at  the  same  time, 
and  are  convinced  that  with  a  clean  operator  an  open  method  is  as  safe  as  the 
treatment  with  splints,  and  has  all  the  other  advantages  just  mentioned. 

Technique.  A  transverse,  curved  incision  is  made  with  its  center  three  centi- 
meters below  the  point  of  the  fracture  of  the  patella.  This  flap  is  turned  up ; 
the  blood  clots  found  to  be  present  are  sponged  aw^ ay  w-ith  moist  aseptic  gauze 
pads ;  the  two  fragments  are  then  placed  in  accurate  apposition ;  and  the 
capsule  to  each  side  of  the  fracture  is  sutured  bj^  means  of  chromicized  cat- 
gut, wdiicli  will  last  about  tw^o  weeks.  A  iew  superficial  sutures  are  then 
applied  to  hold  the  patella  in  accurate  apposition,  and  the  skin  sutured  over 
all.  A  small  plaster-of-Paris  cast  is  then  applied  and  the  patient  placed  in 
bed,  with  the  extremity  elevated.  It  is  important  that  the  extremity  should 
be  elevated,  because  this  relaxes  the  quadriceps  femoris  muscle  and  conse- 
quently prevents  pulling  upon  the  upper  fragment. 

After  six  or  eight  days  the  patient  is  permitted  to  sit  up  out  of  bed,  and 
after  three  weeks  he  is  allowed  to  walk,  with  a  cast  upon  the  extremity.  Five 
or  six  weeks  after  the  operation  the  east  is  removed  and  the  patient  per- 
mitted to  walk  with  a  cane.  It  is  neither  necessary  nor  desirable  that  the 
patient  should  walk  with  a  crutch  at  any  time.  In  case  there  should  be  a  cer- 
tain amount  of  limitation  of  motion  in  the  knee  after  recovering  from  this 
operation,  which,  in  our  experience,  has  been  very  rare,  this  can  be  overcome 
most  readily  by  having  the  patient  ride  a  bicycle,  or  a  tricycle  if  he  is  not 
accustomed  to  the  former. 

The  result  is  so  much  better  after  this  treatment  than  after  the  methods 
ordinarily  in  vogue  that  we  believe  it  should  become  a  recognized  method, 
only,  however,  in  the  hands  of  clean  surgeons. 

FRACTURE  OF  THE  OLECRANON 

The  recovery  from  a  fracture  of  the  olecranon  is  ordinarily  so  much  easier, 
and  the  conditions  after  healing  are  so  -perfect  if  the  fragments  are  united 
by  the  use  of  catgut  sutures,  that  here  also  an  operation  is  indicated. 

Technique.  A  longitudinal  incision  is  made  directly  over  the  middle  line 
of  the  olecranon  process  and  the  soft  tissues  are  carefully  retracted  in  order 
to  avoid  injuring  the  ulnar  nerve.  It  is  important  at  this  point  for  the  sur- 
geon to  bear  in  mind  the  relative  position  of  the  olecranon  and  the  ulnar 
nerve,  as,  if  the  operation  is  performed  with  the  hand  in  the  position  of  pro- 
nation the  surgeon  may  be  confused  by  the  fact  that  ordinarily  we  carry 
the  relations  in  our  mind  with  the  hand  in  the  position  of  supination.  The 
nerve  mentioned  passes  between  the  internal  condyle  and  the  olecranon,  but 
when  the  hand  is  pronated  so  as  to  place  the  olecranon  in  a  convenient  po- 
sition for  operation,  then  the  internal  condyle  is  turned  to  the  outer  side. 
If  this  fact  is  borne  in  mind  the  nerve  may  be  very  easily  avoided.  Here, 
again,  the  fragments  of  bone  are  united  by  means  of  chromicized  catgut, 
which  will  last  about  fifteen  days.  In  case  a  sufficiently  firm  hold  can  be 
obtained  by  passing  these  sutures  through  the  periosteum  and  the  surround- 


SURGERY  OF  THE  EXTREMITIES  683 

ing  soft  tissues  to  retain  the  fragments  in  perfect  juxtaposition  that  is  all 
that  will  be  required.  If  this  cannot  be  done  a  small  opening  should  be 
drilled  through  the  middle  of  the  olecranon  process  and  through  the  upper 
end  of  the  ulna,  and  a  suture  passed  through  this.  The  arm  should  be  dressed 
in  the  extended  position  by  means  of  a  plaster-of-Paris  cast. 

FRACTURE  OF  THE  ACROMION  PROCESS 

In  fracture  of  the  acromion  process,  in  which  it  is  found  difficult  to  main- 
tain the  proper  position,  an  incision  should  be  made  parallel  with  the  spine 
of  the  scapula,  the  fracture  should  be  exposed  with  as  little  disturbance  of  the 
soft  tissues  as  possible,  and  the  fractured  end  sutured  in  place,  if  possible,  by 
'passing  the  sutures  through  the  soft  tissues.  If  it  is  not  possible  to  firmly 
adjust  the  fragments  in  this  manner  small  openings  should  be  drilled  into  the 
end  of  each  fragment  and  at  least  two  chromicized  catgut  sutures  applied  in 
order  to  secure  a  perfect  coaptation. 

FRACTURES  OF  THE  OUTER  END  OF  THE  CLAVICLE 

In  very  rare  instances  a  fracture  occurs  near  the  outer  extremity  of  the 
clavicle  which  cannot  be  retained  in  any  reasonable  position  by  means  of 
dressings  ordinarily  used  for  this  purpose.    In  such  event  the  most  superficial 


^i^SiSKaS!!, 


Fractuke  of  the  Uuteu  Thjkl)  of  Clavicle. 

portion  of  the  bone  should  be  sought,  namely,  upon  the  line  between  the 
attachment  of  the  trapezius  muscle  and  the  deltoid,  and  an  incision  at  this 
point  should  expose  the  fracture,  which  can  then  be  readily  adjusted  by  means 
of  a  few  catgut  sutures.  After  these  have  been  applied  the  skin  is  sutured 
and  a  rubber  adhesive  plaster  applied  upward  from  the  chest,  covering  both 
fragments  and  extending  backward  over  the  scapula.  The  arm  is  then  placed 
in  a  sling  and  carried  in  this  position  for  a  period  of  three  to  six  weeks. 

In  these  cases  we  now  frequently  use  the  Lane  plates  because  they  hold 
the  ends  in  absolute  coaptation  and  produce  ideal  results. 


684  SURGERY  OF  THE  EXTREMITIES 

In  the  same  region  occasionally  a  severe  traumatism  causes  a  dislocation 
of  the  outer  end  of  the  clavicle,  loosening  its  attachment  to  the  acromion  pro- 
cess of  the  scapula,  the  acromio-clavicular  ligaments  being  completely  lacer- 
ated. Ordinarily  this  dislocation  can  be  reduced  by  means  of  properly  applied 
rubber  adhesive  straps,  but  if  such  a  result  is  found  impossible  then  the  inci- 
sion which  has  just  been  described  for  the  treatment  of  a  fracture  at  the  outer 
end  of  the  clavicle  should  be  made,  the  dislocation  reduced,  and  the  ruptured 
acromio-clavicular  ligaments  carefully  sutured  with  chromicized  catgut.  The 
dressing  just  described  in  connection  with  the  rubber  adhesive  plaster  dress- 
ing should  be  applied  and  a  second  broad  strap  of  rubber  adhesive  plaster 
adjusted  as  follows :  Beginning  about  the  angle  of  the  eighth  or  tenth  rib  the 
plaster  is  passed  upwards  and  outwards,  so  that  its  middle  portion  strikes 
the  end  of  the  clavicle.  It  is  then  carried  forwards  and  downwards  and  passed 
around  the  forearm  four  centimeters  below  the  end  of  the  olecranon  process 
wath  the  arm  in  the  flexed  position.  In  this  manner  the  leverage  of  the  arm 
upon  the  adhesive  plaster  straps  serves  to  hold  down  the  end  of  the  clavicle 
in  position  and  relieves  the  tension  upon  the  chromicized  catgut  sutures. 

EPIPHYSEAL  FRACTURES 

In  epiphyseal  fractures  in  any  portion  of  the  skeleton  in  which,  after 
careful  manipulation  under  anesthesia,  it  is  found  impossible  to  adjust  the 
fragments,  it  is  desirable  to  resort  to  an  open  operation  at  once — always  pro- 
viding that  the  surgeon  completely  controls  the  conditions  of  asepsis.  The 
deformities  which  occur  after  these  fractures  are  unusually  annoying,  because 
of  their  proximity  to  the  joints.  This  fact,  of  course,  makes  the  open  opera- 
tion more  hazardous,  but  the  benefits  of  the  operation  are  so  great  in  cases 
in  which,  after  careful  trial,  it  has  been  found  impossible  to  adjust  the  frag- 
ments, that  the  surgeon  is  justified  in  taking  the  additional  risk.  Where  the 
fractures  have  not  been  adjusted  there  will  be  found  a  retardation  of  growth 
from  the  epiphyseal  line  involved,  aside  from  the  deformity.  Whether  this 
can  always  be  avoided  by  an  open  operation  it  is  impossible  to  say  with  the 
relatively  small  amount  of  clinical  observation  upon  this  subject,  but  in  cases 
in  which  the  operation  has  been  done  the  results  have  been  much  more  satis- 
factor}^  than  in  those  in  which  the  irreducible  deformity  has  been  permitted 
to  persist. 

In  the  majority  of  cases  of  epiphyseal  fractures,  the  fragments  can  be 
retained  in  good  position  after  they  have  been  replaced  by  open  operation, 
without  the  introduction  of  any  foreign  body,  such  as  nails,  screws,  wire  or 
plates.  If  in  any  given  case  it  becomes  necessary  to  introduce  a  nail  or  screw 
across  the  epiphyseal  line  it  should  be  removed  as  soon  as  union  has  taken 
place,  so  as  not  to  interfere  with  the  growing  line. 

NON-UNION  OF  THE  NECK  OF  THE  FEMUR 

In  all  cases  of  non-union  of  the  neck  of  the  femur,  and  in  a  few"  cases  of 
primary  fracture  of  the  neck  of  the  femur,  in  which  it  does  not  seem  likely  that 
a  good  result  can  be  obtained  by  non-operative  treatment,  the  use  of  a  large 
bone  peg  is  the  operation  of  choice.  The  fragments  are  exposed  in  the  usual 
manner,  and  the  ends  of  the  fragments  freshened  by  a  sharp  curette  or  chisel, 
and  all  redundant  soft  tissue  removed,  so  that  it  cannot  possibly  slide  in  be- 
tween the  fragments.  The  fragments  are  now  brought  in  as  near  normal  to 
position  as  possible,  and  fixed  temporarily  by  passing  two  Lane  bone  drills  up 
through  the  shaft  and  neck  into  the  head  of  the  femur.  A  bone  graft  about 
one-half  inch  in  width  is  now  cut  from  the  tibia  and  is  driven  up  through  the 


SURGERY  OF  THE  EXTREMITIES  685 

shaft  and  neck  into  the  head  of  the  femur,  which  makes  a  firm  fixation  of  the 
fragments.  The  wound  is  closed  in  the  usual  manner,  and  hip  immobilized 
with  a  plaster-of-Paris  cast  for  a  period  of  fourteen  weeks. 

For  a  number  of  years  the  authors  used  long  wood  screws  as  a  means  of 
fixation,  with  satisfactory  results  in  every  case.  This  method  has  the  advantage 
over  the  various  forms  of  nails  in  that  one  can  draw  the  fragments  in  closer 
apposition  and  the  screw  does  not  loosen  as  easily  as  nails. 

After  the  fragments  have  been  freshened  by  a  sharp  curette  or  chisel  and 
brought  into  apposition,  a  steel  screw  about  three  inches  in  length  is  selected 
and  a  hole  somewhat  smaller  than  the  screw  is  drilled  through  the  femur  at  a 
point  about  one  inch  below  the  great  trochanter,  passing  through  the  neck 
into  the  head  of  the  bone.  The  screw  is  placed  and  turned  in  until  the  two 
fragments  are  drawn  into  close  union.  A  tenpenny  nail  is  then  driven  in  at  a 
point  about  half  to  three-quarters  of  an  inch  distant  from  the  screw  and  at  a 
slightly  different  angle.     This  prevents  rotation  of  the  head  upon  the  shaft. 

CONGENITAL  DISLOCATION  OF  HIP 

Causation.  Congenital  dislocation  of  one  or  both  hips  is  quite  a  common 
condition,  but  frequently  the  true  condition  is  not  recognized  until  the  child 
has  reached  an  age  when  the  treatment  is  very  difficult.  There  is  little  kno-\^Ti 
about  the  etiology  of  this  condition,  although  several  causes  have  been  sug- 
gested by  various  authors,  viz.,  injury  to  the  mother  during  pregnancy;  an 
abnormally  small  amount  of  liquor  amnii ;  injury  at  time  of  birth  and  retarda- 
tion of  growth  of  the  acetabulum.  The  correctness  of  these  opinions  has  never 
been  proven  or  disproven,  nor  has  any  one  been  able  to  explain  why  the  con- 
dition happens  about  seven  times  as  often  in  girls  as  in  boys. 

Pathology.  Most  observers  seem  to  agree  that  when  present  the  acetabulum 
is  always  in  the  right  place,  and  some  state  that  however  rudimentary  the 
acetabulum  may  be,  it  is  always  present.  The  acetabulum  is  usually  very 
shallow,  because  in  the  first  place  it  has  not  developed  fully,  and,  secondly, 
it  is  more  or  less  filled  with  cartilaginous,  fibrous  or  fatty  substance.  The 
head  of  the  femur  is  usually  normal,  or  nearly  so,  in  size,  so  consequently  it 
is  always  disproportionately  large.  The  ligamentum  teres  may  be  absent 
or  drawn  out  into  a  long,  thin  band.  The  capsule  is  greatly  elongated  and 
often  has  an  hour-glass  constriction  at  its  middle.  In  double  dislocation  the 
pelvis  hangs  on  the  femora  by  the  drawn-out  capsule,  instead  of  resting  upon 
and  being  directly  supported  by  the  heads  of  the  femora.  The  pelvi-femoral 
and  Dclvi-crural  muscles  are  shortened. 

Signs  and  symptoms.  The  signs  and  symptoms  differ  somewhat  according 
to  whether  the  dislocation  is  single  or  double.  For  convenience  we  have 
divided  them  into  three  groups. 

Group  1  comprises  those  com.mon  to  both  forms  of  dislocation;  Group  2. 
those  which  are  found  only  in  double  dislocations ;  and  Group  3,  those  which 
are  found  only  in  single  dislocations. 

Grouf)  1.  Prominence  of  the  buttocks.  This  is  sometimes  very  marked, 
having  the  appearance  of  a  lipomatous  tumor.  The  upper  border  of  the  great 
trochanter  projects  well  above  Nelaton's  line.  The  head  can  be  felt  on  the 
posterior  surface  of  the  acetabulum,  and  there  is  a  depression  instead  of  a 
prominence  in  the  groin  just  external  to  the  femoral  vessels.  If  the  pelvis 
is  grasped  firmly  and  traction  made  on  the  thigh,  the  head  can  be  felt  to 
move  downward'without  imparting  the  motion  to  the  pelvis,  i.e.,  undue  passive 
motion  at  the  hip,  though  active  motion  is  usually  about  normal.  The  patients 
learn  to  walk  late,  fall  easily  at  first,  are  easily  fatigued,  and  Avhen  they  become 


686  SURGERY  OF  THE  EXTREMITIES 

very  tired  often  experience  a  dull,  aching  pain  at  the  hip  and  knee.  A  good 
skiagraph  always  shows  the  dislocation. 

Group  2.  Waddling,  duck-like  gait;  more  or  less  marked  lordosis;  promi- 
nence of  the  abdomen;  squat  figure.  This  last  can  be  determined  by  careful 
measurements.  It  can  always  be  demonstrated  that  there  is  a  disproportion 
between  the  distance  from  the  anterior  superior  spines  of  the  ilii  to  the  inter- 
nal malleoli  and  the  height  of  the  body. 

Group  3.  Marked  limp ;  pronounced  scoliosis ;  shortening  of  the  affected 
limb  as  determined  by  measuring  from  the  anterior  superior  spine  to  internal 
malleolus. 

Diagnosis.  If  in  each  individual  ease  of  deformity  of  the  hip  or  back  we 
will  but  remember  the  possibility  of  its  being  a  congenital  dislocation  of  the 
hip,  and  recall  the  above  enumerated  signs  and  sj^mptoms,  the  diagnosis  is 
usually  easy,  as  in  each  case  all,  or  nearly  all,  of  them  can  be  found.  In  the 
past  a  goodly  number  of  these  cases  have  been  diagnosed  as  coxitis,  simple 
spinal  curvature,  infantile  paralysis,  rickets,  or  Pott's  disease.  In  every 
patient  where  this  condition  is  suspected,  an  X-ray  picture  should  be  taken, 
and  if  present  the  head  of  the  femur  will  be  sliown  to  be  a  considerable  dis- 
tance above  the  acetabulum,  making  the  diagnosis  positive. 

Treatment.  During  the  past  sixteen  years  the  authors  have  used  the 
"bloodless  functional  Aveight  method"  of  Lorenz  with  excellent  results  in  the 
majority  of  cases. 

Reduction  is  accomplished  in  the  following  manner :  It  is  necessary,  first, 
that  a  general  anesthetic  be  used  to  secure  a  state  of  complete  relaxation. 
Then  while  one  or  two  assistants  hold  the  pelvis  of  the  patient,  the  operator 
grasps  the  thigh  just  above  the  knee  and  makes  a  steady  downward  pull,  rota- 
ting the  thigh  back  and  forth  somewhat  while  the  traction  is  made.  As  soon 
as  the  upper  border  of  the  trochanter  is  well  down  to  Nelaton's  line,  the  first 
step  has  been  accomplished.  It  is  next  necessary  to  bring  the  thigh  into  a 
position  of  complete  abduction,  which  is  so  essential  in  making  the  head  slip 
over  the  posterior  rim  of  the  acetabulum.  This  is  accomplished  by  steady, 
moulding  manipulations.  Sudden  jerks  should  be  avoided  because  Avhile  secur- 
ing abduction  one  is  liable  to  fracture  the  neck  of  the  femur.  If  abduction 
to  a  right  angle  cannot  be  accomplished,  subcutaneous  tenotomy  of  the  ad- 
ductors must  be  resorted  to. 

As  soon  as  the  required  degree  of  abduction  has  once  been  accomplished, 
the  pelvis  is  steadied  by  an  assistant,  the  thigh  is  flexed  to  a  right  angle  and 
slightly  rotated  inwardl.y.  AA^hile  one  hand  of  the  operator  presses  on  the 
trochanter,  the  other  hand  makes  strong,  steady  traction  forward,  and  at  the 
same  time  attempts  slow  abduction.  The  head  slowly  creeps  up  over  the 
posterior  border  of  the  acetabulum,  and  suddenly  slips  over  the  rim,  bounds 
into  the  acetabulum  with  a  distinct  thud,  which  sometimes  can  be  heard  at  a 
considerable  distance,  and  with  a  vibration  of  the  patient's  body,  which  is 
always  transmitted  to  the  operator,  and  sometimes  even  to  the  table  and  to 
those  who  may  be  in  contact  with  it. 

The  other  signs  of  an  accomplished  reposition  are :  Distinct  length- 
ening of  the  thigh ;  the  development  of  a  fullness  in  the  groin  and  the  disap- 
pearance of  the  head  of  the  femur  on  the  posterior  surface  of  the  ilium ;  and 
the  sudden  tenseness  of  the  hamstring  tendons  characterized  by  inability  to 
extend  the  knee.  The  object  of  the  inward  rotation  is  to  loosen  the  capsule 
from  the  rim  of  the  acetabulum  and  to  utilize  the  head  of  the  femur  as  a  wedge 
to  open  up  any  hour-glass  constriction  in  the  capsule.  Reposition  having 
been  accomplished,  we  must  now  make  every  effort  that  this  be  rendered 
stable.  This  is  secured,  first  by  a  boring  motion.  The  thigh  is  rotated  out- 
ward, and  with  a  boring  motion  the  anterior  capsule  is  stretched  and  the 


I 


SURGERY  OF  THE  EXTREMITIES  687 

acetabulum  deepened ;  second,  the  tense  pelvi-f emoral  and  pelvi-crural  muscles 
will  help  to  deepen  and  enlarge  the  acetabulum ;  and,  finally,  third,  the  weight 
of  the  body  in  walking  will  greatly  aid  the  formation  of  a  satisfactory  joint  in 
removing  the  deposits  in  the  acetabulum  and  securing  the  development  of  a 
broad  cotyloid  ligament.  In  order  to  fully  utilize  this  important  principle  a 
cast  must  be  applied  with  the  thigh  in  complete  abduction  and  at  right  angles 
to  the  acetabulum  in  all  directions.  The  cast  should  be  applied  over  two  thick- 
nesses of  stockinette  and  include  the  entire  thigh  and  pelvis  as  high  as  the 
umbilicus.  This  degree  of  abduction  does  away  with  any  tendency  of  the  head 
to  slip  out  of  the  rudimentary  acetabulum.  The  child  is  allowed  to  walk  as 
soon  as  it  wishes. 

In  single  dislocations  a  high  sole  is  placed  under  the  shoe  of  the  operated 
leg  so  as  to  make  walking  a  little  more  comfortable.  In  double  cases  a  stool 
can  be  made  on  which  the  child  may  sit  astride  and  still  bear  the  weight  on  the 
feet. 

The  first  cast  is  worn  four  months,  when  it  is  removed,  and  the  thigh 
brough  down  to  an  angle  of  forty-five  degrees  of  abduction  and  slight  flexion, 
and  another  cast  applied  in  this  position.  This  cast  is  worn  about  eight  to  ten 
months,  when  the  child  can  usually  go  without  any  appliances.  While  wearing 
the  casts  the  child  should  be  encouraged  to  walk  a  great  deal,  as  that  will 
help  to  deepen  and  develop  the  acetabulum  and  to  strengthen  the  muscles  of 
the  thigh  and  the  structures  of  the  joint. 

Prognosis.  If  one  succeeds  in  replacing  the  head  in  the  acetabulum  the 
chances  of  a  complete  and  permanent  recovery  are  very  good.  In  cases  of 
single  dislocation  in  patients  six  years  of  age  or  younger,  and  in  double  cases 
five  years  of  age  or  younger,  reduction  of  the  dislocation  can  usually  be 
accomplished  by  the  Lorenz  method.  Occasionally  reduction  can  be  made  in 
patients  quite  a  little  older  than  the  ages  given  above.  The  most  favorable 
time  for  treatment,  however,  is  when  the  patient  is  between  three  and  one- 
half  and  four  years  old. 

BONE  TRANSPLANTATION 

Osteogenesis.  The  operation  of  bone  transplantation  has  become  a 
thoroughly  established  surgical  procedure,  but  there  still  exists  considerable 
controversy  as  to  the  manner  of  regeneration  of  bone  or  upon  what  it  depends. 
Among  the  various  views  upon  this  point  are  those  of  Axhousen,  who  maintains 
that  the  bone  in  the  graft  always  dies,  and  that  it  possesses  power  of  regen- 
eration by  virtue  of  its  periosteum.  On  the  other  hand,  Macewen  claims  that 
the  bone  in  a  graft  is  reproduced  from  the  osteoblasts  within  the  bone  of  the 
graft  itself  and  that  the  periosteum  simply  acts  as  a  limiting  membrane  to  keep 
the  osteoblasts  from  spreading  into  the  surrounding  tissues.  Another  view  is 
that  of  Murphy,  who  contends  that  the  graft  is  not  osteogenetic,  but  simply 
osteo-conductive.  That  a  bone  graft  when  placed  in  contact  with  other  living 
bone  acts  simply  as  a  mechanical  support  for  the  Haversian  blood  vessels  and 
the  living  osteogenetic  cells  as  they  advance  from  the  living  bones  at  both 
ends  and  pass  through  the  Haversian  canals,  canaliculi  and  lacuna  of  the 
transplant. 

Phemister,  after  a  long  series  of  experiments,  came  to  the  conclusion  that 
osteogenesis  in  bone  repair  occurs  from  the  inner  layer  of  the  periosteum, 
from  the  endosteum  and  to  a  much  less  extent  from  the  bone  cells  and  fibrous 
contents  of  the  Haversian  canals.  The  viability  of  the  cells  of  the  transplant 
is  dependent  largely  upon  their  ability  to  get  nutrition.  Periosteum  and 
endosteum  being  located  superficially  receive  sufficient  nourishment  to  sur- 
vive and  proliferate.    The  great  mass  of  bone  cells  being  away  from  the  sur- 


688  SURGERY  OF  THE  EXTREMITIES 

face  and  siirroimded  by  an  extensive,  calcified  matrix  gradually  undergo 
necrosis  and  absorption.  McWilliams,  after  a  series  of  experiments,  states 
that  "The  life  of  a  living  graft  depends  entirely  on  its  receiving  sufficient 
blood  to  keep  it  alive  and  nothing  else.  The  presence  of  periosteum  on  a 
graft  has  a  favorable  influence  on  the  nutrition  of  the  graft,  that  is,  increases 
the  blood  supply  to  its  cells,  so  as  to  keep  it  alive,  or  in  case  the  bone  cells  in 
the  graft  die  from  insufficient  nourishment,  the  periosteum  supplies  living 
cells  to  the  graft,  by  means  of  which  the  bone  is  regenerated." 

After  carefully  considering  all  of  the  various  experiments  it  seems  as  if 
the  conclusions  of  Phemister  and  McWilliams  are  probably  correct,  that  is, 
that  in  bone  transplantation  the  regeneration  takes  place  from  the  inner 
layer  of  the  periosteum,  the  endosteum  and  somcAvhat  from  the  bone  cells 
and  fibrous  contents  of  the  Haversian  canals,  and  that  the  life  of  the  graft 
depends  entirely  on  its  receiving  sufficient  blood  supply  to  keep  it  alive. 

The  practical  conclusion  to  be  drawn  from  all  of  the  various  experiments 
on  bone  transplantation  is,  that  in  order  to  be  assured  of  the  subsequent 
vitality  of  a  bone  graft,  as  much  of  the  periosteum  as  can  be  obtained  should 
accompany  the  graft. 

Indications  for  bone  transplantation.  1.  For  the  repair  of  recent  or  un- 
united fractures. 

2.  To  replace  bone  which  has  been  destroyed  by  infection,  such  as  osteo- 
myelitis, tuberculosis,  etc. 

3.  To  replace  bone  that  has  been  removed  because  of  having  been  the 
seat  of  a  non-malignant  neoplasm,  such  as  cySts  and  osteitis  fibrosa  cystica. 

4.  To  replace  bone  that  has  been  removed  in  cases  of  encapsulated  ma- 
lignant disease,  such  as  giant-celled  sarcoma. 

5.  To  produce  a  bony  ankylosis  of  the  vertebrae,  in  cases  of  Pott's  disease 
of  the  spine,  as  deyised  by  Albee,  and  also  to  produce  an  ankylosis  of  the 
spine  in  cases  of  fracture  of  the  vertebra-. 

6.  To  correct  bony  deformities,  either  congenital  or  acquired,  such  as 
saddle-nose. 

Important  features  of  the  bone  grafting  operation.  1.  It  is  absolutely 
necessary  that  the  strictest  asepsis  be  maintained  throughout  the  entire 
operation,  as  primary  union  is  essential  to  insure  good  results.  The  field  of 
operation  should  be  aseptic,  that  is,  a  graft  should  not  be  placed  in  an  area 
that  is  not  primarily  aseptic. 

2.  The  transplant  should  be  placed  in  contact  Avith  living  bone,  at  least 
at  one  end,  and  preferably  at  both  ends. 

3.  The  graft  should  be  taken  from  the  patient  himself.  The  crest  of  the 
tibia  is  a  very  suitable  area  from  which  to  remove  the  transplant,  as  it  is 
easily  accessible,  and  a  graft  of  most  any  length  can  be  obtained.  Taking  a 
graft  from  this  region  does  not  incapacitate  the  patient  at  all,  as  it  does  not 
interfere  with  the  weight-bearing  power  of  the  tibia. 

4.  The  transplant  should  be  large  enough  to  give  a  firm,  immediate 
mechanical  support.  Its  length  should  be  considerably  more  than  the  gap  it 
is  to  fill,  so  that  it  can  be  securelv  fastened  at  both  ends,  giving  it  as  much 
contact  with  living  bone  as  is  possible. 

5.  To  insure  success  the  transplant  should  be  covered  with  periosteum. 

6.  In  removing  the  graft,  which  can  readily  be  done  either  with  a  car- 
penter's chisel  or  one  of  the  various  electrical  saws,  care  should  be  used  to 
preserve  the  integrity  of  the  graft. 

7.  The  extremity  in  which  the  graft  has  been  placed  should  be  supported 
by  some  form  of  external  splint  for  a  period  of  eight  to  twelve  weeks,  as  it 
takes  this  length  of  time  for  the  graft  to  become  firmly  attached.  After  the 
external  support  has  been  removed,  the  patient  should  be  very  cautious  in 


SURGERY  OF  THE  EXTREMITIES  689 

the  use  of  the  extremity  for  another  six  months,  as  it  requires  from  six  to 
twelve  months  for  a  bone  to  become  restored  to  its  normal  size. 

OSTEOMYELITIS 

Patients  suffering  from  acute  osteomyelitis  usually  give  a  history  of  a  sud- 
den attack  of  pain,  most  frequently  at  the  point  of  entrance  of  the  nutrient 
artery  or  near  one  of  the  epiphyseal  extremities  of  one  of  the  long  bones.  This 
attack  usually  occurs  after  exposure  to  -wet  and  cold. 

In  many  cases  it  is  possible  to  trace  a  history  of  follicular  tonsillitis  as  the 
source  of  the  infection.  The  pain  is  extreme  upon  pressure  and  most  extreme 
early  in  the  disease  at  one  particular  circumscribed  point.  The  patient  has 
high  fever  and  feels  thoroughly  ill,  having  the  general  appearance  of  one  suf- 
fering from  acute  sepsis.  The  pain  becomes  more  and  more  diffuse  and  the 
extremity  becomes  swollen  and  later  on  edematous  and  reddened,  and  ulti- 
mately fluctuation  will  appear.  In  a  very  large  proportion  of  these  cases  the 
early  diagnosis  is  that  of  localized  rheumatism,  and,  vice  versa,  conditions  giv- 
ing rise  to  a  diagnosis  of  localized  rheumatism  near  the  center  of  a  long  bone, 
or  near  one  of  the  epiphyseal  lines,  practically  always  means  that  the  patient  is 
suffering  from  acute  osteomyelitis.  In  many  the  disease  seems  to  have  been 
located  by  a  slight  traumatism.  Of  course,  it  is  always  necessary  to  bear  in 
mind  that  the  osteomyelitis  may  have  existed  and  that  the  traumatism  was  but 
a  coincidence. 

Operative  technique.  It  is  necessary  only  to  bear  in  mind  the  pathological 
conditions  present  in  order  to  determine  the  proper  treatment.  There  is  a 
violent  circumscribed  infection  which,  if  left  undisturbed,  is  certain  to  pro- 
gress along  the  blood  vessels  and  lymph  channels  and  become  more  and  more 
diffuse.  The  bone  is  surrounded  by  a  tense  membrane,  the  periosteum,  and 
consequently  the  products  of  the  infection  cannot  easily  escape,  and  the 
pressure  caused  by  these  against  the  sensitive  periosteum  gives  rise  to  the 
excruciating  pain.  It  is  plain,  then,  that  in  order  to  secure  relief  from  pain 
conditions  must  be  established  providing  for  the  escape  of  the  products  of 
infection  confined  within  the  periosteum.  This  may  be  accomplished  most 
readily  by  making  a  long  incision  through  all  of  the  tissues  down  through  the 
periosteum.  Such  treatment  at  once  permits  the  septic  material  to  escape,  it 
relieves  the  pressure,  stops  the  pain,  and  directs  the  lymph  stream  away  from 
the  body  and  therefore  prevents  the  progress  of  the  infection. 

A  number  of  years  ago  many  excellent  surgeons  at  once  removed  the  in- 
fected bone.  In  some  instances  the  entire  shaft  of  one  of  the  long  bones  was 
found  diseased  and  entirely  removed,  and  it  seemed  as  though  this  was  the 
only  logical  way  of  treating  so  intense  an  infection.  However,  experience  has 
taught  that  in  these  cases  in  which  large  portions  of  bone  in  acute  osteomyelitis 
were  removed  there  was  no  reproduction  of  new  bone  to  take  the  place  of  that 
removed,  and  consequently  the  extremity  was  left  without  bony  support.  On 
the  other  hand,  it  was  found  that  if  the  periosteum  was  simply  split  open  the 
recovery  was  exceedingly  rapid  from  the  acute  attack,  and  many  times  a  bone 
which  seemed  entirely  lost  regained  its  vitality  and  continued  to  perform  its 
physiological  functions,  while  in  other  instances  a  bone  which  seemed  entirely 
destroyed  regained  its  vitality  to  a  great  extent  and  it  was  later  necessary  to 
remove  only  a  small  portion  of  necrotic  osseous  tissue.  Again,  experience  has 
taught  that  so  long  as  the  diseased  bone  was  left  in  place  there  was  rapidly 
produced  between  this  portion  and  the  periosteum  a  layer  of  new  bone,  known 
as  the  involucrum,  which  in  a  few  months  became  strong  enouffh  to  substitute 
the  diseased  bone  after  this  was  removed,  and  in  such  cases  the  reproduction 
of  bone  after  the  removal  of  the  necrotic  bone  tissue  progressed  to  such  an 


690  SURGERY  OF  THE  EXTREMITIES 

extent  that  almost  the  entire  structure  was  reformed.     Moreover,  those  who 
have  frequently  operated  upon  osteomyelitic  bone  have  found  that  even  with- 
out the  aid  of  drainage,  resulting  from  the  incision  just  described,  almost  all 
of  these  patients  suffering  from  acute  osteomyelitis  recover  and  become  chroni 
and  that  then  it  is  possible  to  remove  the  diseased  bone  and  still  leave  a  per 
fectly  useful  support  for  the  extremity  in  the  form  of  the  new  involucrum. 

In  all  cases  of  acute  osteomyelitis,  then,  the  primary  operation  should  con- 
sist in  an  incision  extending  some  distance  beyond  each  end  of  the  infection  in 
the  bone  and  must  penetrate  all  the  tissues  down  to  the  bone,  including  the 
periosteum.  The  drainage  can  be  still  further  improved  by  the  application  of 
large,  moist  antiseptic  dressings  to  the  extremity  and,  of  course,  complete  rest. 
A  saturated  solution  of  boric  acid,  or  of  acetate  of  aluminum,  or  a  thirty  per 
cent,  solution  of  alcohol  in  hot  water,  are  most  useful  fluids  for  this  purpose. 
The  entire  extremity  should  be  enveloped  in  this  dressing  and  covered  with  an 
impervious  substance  like  oiled  silk  or  gutta  percha  tissue,  or  an  ordinary 
rubber  cloth.  Fresh  solutions  should  be  added  three  to  six  times  a  day.  The 
dressing  itself  need  not  be  removed  more  than  once  every  two  to  four  days. 
The  pain  subsides  almost  instantly,  and  within  a  few  weeks  the  incision  usu- 
ally heals,  with  the  exception  of  a  circumscribed  point  in  case  the  bone  does 
not  entirely  recuperate. 

Only  rarely  does  the  surgeon  see  a  case  of  osteomyelitis  at  the  very  begin- 
ning of  the  attack,  when  the  infection  is  still  confined  to  a  limited  area  one  or 
two  centimeters  in  diameter,  which  can  be  located  because  of  the  extreme 
tenderness  in  a  particular  point.  In  these  rare  cases  the  bone  should  be  opened 
with  a  very  sharp  chisel.  The  infected  tissue  should  be  gouged  and  scraped 
out  with  great  care  and  the  cavity  filled  with  ninety-five  per  cent,  carbolic 
acid  for  five  to  ten  minutes,  and  then  thoroughly  washed  with  strong  alcohol. 
The  skin  may  be  sutured  over  this  directly  or  the  cavity  tamponed  for  a  few 
days  and  then  sutured  secondarily. 

In  the  event  of  a  circumscribed  portion  of  bone  becoming  necrotic  it  should 
be  left  in  place  until  it  has  been  thoroughly  covered  by  an  involucrum,  devel- 
oped between  the  necrotic  bone  and  the  periosteum.  After  this  has  become 
sufficiently  strong  to  support  the  extremity  it  should  be  treated  after  the 
method  to  be  described  in  connection  with  chronic  osteomyelitis  here  following, 

CHRONIC  OSTEOMYELITIS 

Patients  suffering  from  this  disease  most  commonly  give  a  history  of  acute 
osteomyelitis,  which  may  have  been  treated  after  the  method  just  described,  or, 
more  frequently,  have  been  diagnosed  as  acute  localized  rheumatism  and 
treated  accordingly.  Often  the  condition  has  progressed  to  the  formation  of 
an  abscess,  which  may  have  ruptured  spontaneously  or  been  laid  open  by  the 
surgeon.  The  sinus  resulting  from  this  abscess  refuses  to  heal  entirely,  or  it 
may  heal  and  open  from  time  to  time,  the  patient  feeling  comparatively  com- 
fortable whenever  the  sinus  is  open  and  suffering  from  pain  when  it  is  closed. 

The  infection  may  be  due  to  one  or  more  of  the  pus  microbes,  to  the 
typhoid  bacillus,  the  pneumococcus  or  to  the  bacillus  of  tuberculosis.  If  the 
latter  form  of  infection  exists  alone  the  onset  and  the  progress  of  the  disease 
is  usually  slower  than  if  due  to  any  of  the  other  micro-organisms  mentioned. 

The  condition  must  be  differentiated  from  syphilitic  osteitis  or  periostitis. 
The  latter  is  preceded  by  a  history  of  syphilis  or  of  hereditary  syphilis,  or 
there  may  have  been  syphilitic  infection  without  any  obtainable  history.  The 
progress  of  this  condition  is,  however,  slmv ;  it  is  characterized  by  less  acute, 
or  rather  more  deep-seated,  pain,  which  is  likely  to  be  more  severe  at  night 
than  during  the  day-time.     The  characteristic  mark  of  this  disease,  however. 


u 

i 


SUEGERY  OF  THE  EXTREMITIES  691 

is  the  spindle-shaped  appearance  of  the  diseased  bone  and  the  tendency  to 
elongation  and  bending  of  the  bone,  in  case  the  long  bones  are  involved,  Avhich 
is  not  very  common  except  in  the  tibia  and  occasionally  the  femur.  Syphilis 
more  commonly  attacks  the  flat  bones ;  tuberculosis  the  joints,  the  epiphyses 
and  the  short  bones;  while  osteomyelitis  most  commonly  involves  the  long 
bones. 

The  diagnosis  of  sj^ohilitic  osteitis  or  periostitis  may  be  eliminated  by  the 
administration  of  salvarsan,  by  the  vigorous  use  of  mercury,  and  by  large 
doses  of  iodide  of  potash  continued  for  a  period  of  from  two  to  six  weeks. 
If  no  distinct  improvement  occurs  the  condition  is  probably  not  due  to  syph- 
ilis. Very  rarely  is  there  any  diificulty  in  making  a  differential  diagnosis 
between  osteomyelitis  and  sarcoma,  because  in  the  latter  there  is  the  distinct 
formation  of  a  tumor. 

Operative  technique.  The  treatment  of  chronic  osteomyelitis  consists  in 
laying  bare  the  diseased  bone,  reflecting  the  periosteum,  chiseling  away  a 
sufficient  amount  of  the  involucrum  to  permit  of  the  removal  of  the  necrotic 
bone;  then  the  involucrum  should  be  chiseled  away  in  each  direction  suffi- 
ciently to  permit  of  the  complete  removal  of  all  infected  tissue.  The  granu- 
lations should  be  curetted  away  until  the  surface  of  bone  is  perfectly  smooth 
and  free  from  any  of  these  structures.  During  the  chiseling  operation  it  is 
frequently  necessary  to  employ  great  care  to  prevent  the  production  of  a 
fracture,  as  if  the  entire  shaft  of  the  bone  has  been  necrotic  the  involucrum 
is  frequently  not  strong  enough  to  bear  any  severe  strain. 

In  planning  an  operation  for  chronic  osteomyelitis  one  should,  if  possible, 
arrange  to  leave  the  conditions  so  that  a  sufficient  amount  of  the  involucrum 
may  safely  be  chiseled  away  to  leave  the  space  caused  by  the  removal  of  the 
sequestrum  entirely  on  one  side  of  the  bone,  so  that  there  will  remain  no 
cavity  which  cannot  be  filled  by  the  falling  in  of  the  surrounding  soft  tissues. 
If,  however,  the  conditions  present  will  not  permit  this,  the  ledge  of  bone  on 
one  side  or  the  other  of  the  groove  formed  after  the  removal  of  the  sequestrum 
should  be  chiseled  parallel  to  the  bone,  remaining  attached,  however,  to  its 
periosteum,  so  that  the  entire  ledge  may  be  folded  in  against  the  remaining 
portion  of  the  bone  which  is  continuous  above  and  below  with  the  healthy 
structure.  This  prevents  the  formation  of  a  cavity  with  unyielding  walls  and 
will  facilitate  healing  after  the  operation  for  chronic  osteomyelitis  very 
greatly.  After  all  of  the  diseased  tissue  has  been  removed  the  surfaces  of 
the  bone  may  be  swabbed  with  ninety-five  per  cent,  carbolic  acid,  which  may 
be  left  in  contact  for  from  two  to  five  minutes,  and  then  the  cavity  should  be 
thoroughly  washed  with  strong  alcohol  to  remove  the  superfluous  carbolic 
acid. 

It  has  been  our  custom  to  apply  strong  compound  tincture  of  iodine  to 
these  surfaces  after  the  alcohol  has  been  sponged  away  and  then  close  the 
wound  with  sutures  and  apply  a  large  antiseptic  dressing,  and  to  support  the 
extremity  by  means  of  a  splint.  If,  however,  there  is  doubt  about  the  com- 
plete removal  of  all  the  infected  tissue,  it  is  much  wiser  to  tampon  the  cavity 
with  iodoform  gauze,  and,  if  found  aseptic  after  a  few  days,  to  close  the 
wound  by  secondary  sutures. 

In  cases  operated  repeatedly  without  permanent  success,  it  is  especially 
desirable  to  obliterate  the  medullary  canal  completely  in  order  to  leave  no 
space  to  become  the  seat  of  a  new  infection,  or  that  may  contain  a  focus  of 
old  infection.  This  can  be  best  accomplished  by  chiseling  away  the  entire 
portion  of  bone  forming  the  walls  of  the  medullary  canal,  except  on  one  side. 
It  is  not  necessary  to  retain  much  bone,  as  repair  will  begin  at  once,  and  in 
a  few  weeks  the  bone  will  again  have  its  normal  size.  It  is,  however,  im- 
portant to  exercise  care  not  to  fracture  the  bone  during  the  operation.     The 


692  SURGERY  OF  THE  EXTREMITIES 

patient  should  be  kept  thoroughly  under  the  influence  of  the  anesthetic,  as  a 
sudden  motion  on  his  part  may  result  in  a  fracture. 

SEPTIC  INFECTION  OF  THE  EXTREMITIES 

Typical  case.  The  patient  is  forty-eight  years  of  age,  works  in  a  lumber  yard,  and  gives 
the  following  history:  His  family  history  is  negative.  He  suffered  from  the  ordinary  dis- 
eases of  childhood;  four  years  ago  he  had  pneumonia,  but  otherwise  has  always  been  well. 
Four  days  ago  he  noticed  a  slight  swelling  of  his  left  thumb,  wliich  was  ascribed  to  the  fact 
that  two  weeks  ago  a  small  sliver  of  wood  entered  at  the  point  of  the  swelling.  At  first  he 
paid  no  attention  to  this,  but  last  night  he  suddenly  began  to  feel  exceedingly  ill.  The 
swelling  extended  rapidly  over  the  entire  hand,  and  red  lines  indicate  the  course  of  the 
superficial  lymph  channels  along  the  palmar  surface  of  the  arm  to  the  axilla.  There  is  a 
very  small  point  at  which  the  sliver  entered  the  end  of  the  thumb.  All  the  infected  portions 
are  exceedingly  tender. 

The  patient  is  a  strong,  well-nourished  man.  A  physical  examination  shows  his  heart, 
lungs,  kidneys  and  abdominal  organs  to  be  normal.  His  temperature  at  the  present  time  is 
102%°  F.,  pulse  124,  respiration  20.  He  has  the  appearance  of  being  extremely  ill.  During 
the  past  night  he  was  delirious,  and  his  friends  state  that  his  fever  was  very  high — although 
the  temperature  was  not  measured. 

If  this  patient  were  permitted  to  sit  up  or  walk  about  "with  some  small 
local  dressing  applied  to  his  thumb,  we  are  certain  that  in  a  few  days  he 
would  develop  a  palmar  abscess,  and  judging  from  the  extension  of  the 
swelling  at  the  present  time,  this  would  later  be  followed  by  an  abscess  of 
the  forearm,  and  still  later  the  axillary  glands  would  suppurate. 

Everj^  practical  surgeon  has  made  the  following  observation  in  these 
patients  many  times,  and  possibly  also  upon  himself.  A  slight  infection  of 
the  finger  occurs  from  a  prick  with  a  needle  or  from  some  other  slight  injury. 
During  the  day  the  finger,  and  even  the  hand,  becomes  painful.  The  next 
morning  the  pain  has  entirely  disappeared  and  the  patient  imagines  himself 
well,  but  during  the  day  the  pain  returns,  perhaps  a  little  more  severe  than 
the  day  before,  and  on  the  following  night  it  again  disappears,  only  to  a  less 
extent.  After  a  few  further  repetitions  a  serious  infection  may  become  estab- 
lished, resulting  in  the  destruction  of  a  considerable  amount  of  tissue,  which 
will  probably  be  followed  by  a  marked  impairment  of  the  function  of  the 
extremity. 

The  explanation  is  very  simple.  During  the  day  when  the  extremity  is 
frequently  moved  the  infectious  material  is  carried  from  its  circumscribed 
area  to  points  farther  up  the  arm.  The  following  night  this  progress  is  again 
inhibited,  because  of  the  complete  rest  in  the  muscles  of  the  arm,  and  there 
is  a  corresponding  diminution  in  the  s^^nptoms.  If  the  rest  be  continued  the 
progress  is  permanently  inhibited  and  the  patient  recovers  completely.  If 
this  is  not  done  it  will  ordinarily  advance  until  he  is  so  ill  that  rest  is  com- 
pulsory. 

Treatment.  Our  treatment  consists  in  carefully  cutting  away  the  thick- 
ened skin  over  the  point  of  the  thumb  in  order  to  permit  any  infectious  ma- 
terial still  existing  at  the  original  point  of  entrance  to  escape.  The  great 
danger  to  the  patient,  however,  comes  from  the  infection  which  has  already 
extended  beyond  the  original  area,  and  we  consequently  apply  to  the  entire 
arm  the  dressing  shown  herewith.  The  patient  will  also  receive  a  cathartic, 
preferably  two  ounces  of  castor  oil  in  the  foam  of  beer  or  malt  extract,  in 
order  to  remove  from  his  alimentary  canal  any  products  of  decomposition 
which  might  depress  his  general  system.  As  a  result  of  this  dressing,  com- 
bined with  absolute  rest,  we  will  expect  the  temperature  to  be  practically 
normal  within  two  days,  and  the  worst  consequence  that  can  happen  lies  in  a 
circumscribed,  harmless  abscess  that  will  heal  within  a  few  days  after  being 
laid  open. 


SURGERY  OF  THE  EXTREMITIES 


693 


Even  the  severest  infections  of  the  extremities,  such  as  may  result  from 
wounds  received  at  post-mortems,  pin  pricks  or  slight  abrasions,  nail  punc- 
tures, etc.,  will  subside  within  a  few  daj^s  if  the  two  very  simple  requirements 
indicated  above  are  established.  The  more  important  of  these  is  rest.  The 
septic  material  is  carried  from  the  original  point  of  infection  through  the 
lymph  channels.  It  is,  however,  a  fact  which  has  been  repeatedly  demon- 
strated, that  this  progress  is  very  slow  if  the  extremity  remains  perfectly  at 
rest,  and  much  more  rapid  if  the  muscles  of  the  arm  are  active,  because  their 
contractions  virtually  pump  the  micro-organisms  onward  in  the  h'mph  chan- 
nels. If  a  patient  suffering  from  an  infection  of  the  hand  or  finger  is  placed 
completely   at  rest  the  inflammation  will  remain  nearly  stationary,   even  if 


Large,  Moist  Antiseptic  Dressing. 

Each  finger  is  first  separately  covered  with  gauze.  Then  the  entire  hand  and  arm  to  the 
shoulder  are  wound  loosely  with  gauze,  then  with  cotton,  all  being  saturated  with  a  mild 
antiseptic  solution.  The  entire  dressing  is  then  covered  with  rubber  cloth  or  some  other 
impervious  material.  The  patient  should  be  in  the  recumbent  position  and  the  extremity 
elevated.     The  object  of  the  pjicture  is  to  show  the  extent  and  size  of  the  dressing. 

there  be  no  further  treatment,  while  as  soon  as  the  patient  begins  to  use  the 
extremity  there  is  a  marked  exacerbation  of  the  inflammation.  This  we  have 
observed  a  great  many  times. 

Antiseptic  dressings.  The  next  important  point  in  the  treatment  consists 
in  the  application  of  large,  moist,  antiseptic  dressings.  It  does  not  matter 
whether  the  infection  be  slight  or  severe  at  first,  one  cannot  feel  certain  that 
it  will  not  increase  in  severity,  and  this  increase  in  severity  may  be  followed 
by  very  unfortunate  results — such  as  palmar  abscesses,  necrosis  of  the  tendon 


694  SURGERY  OF  THE  EXTREMITIES 

sheaths  with  the  subsequent  deformity  and  stiffness,  or  the  axillary  glands 
may  become  involved  and  be  destroyed  by  suppuration,  which  may  be  followed 
by  pyemia  and  death.  This,  however,  will  not  be  the  case  if  the  extremity  is 
put  absolutely  at  rest  as  soon  as  the  diagnosis  is  made  and  a  large,  moist, 
antiseptic  dressing  is  applied.  The  accompanying  plate  illustrates  this  dress- 
ing. It  consists  of  five  to  ten  yards  of  soft,  antiseptic  gauze,  loosely  rolled 
around  each  finger  separately,  then  about  the  hand,  wrist,  forearm  and  arm 
to  the  shoulder.  This  is  surrounded  by  a  pound  of  absorbent  cotton,  and  then 
by  a  rubber  cloth,  to  confine  the  moisture  and  retain  the  temperature.  Fresh 
antiseptic  solution  is  poured  into  the  dressing  every  one  to  six  hours  so  as  to 
keep  the  extremity  constantly  in  contact  with  this  fluid. 

The  dressing  is  renewed  once  in  forty-eight  hours  and  the  entire  extremity 
carefully  inspected  to  locate  circumscribed  abscesses  which  may  form,  although 
the  vast  majority  of  these  cases  get  perfectly  well  without  the  development  of 
an  abscess.  Occasionally  the  circumstances  may  be  such  as  to  make  it  desir- 
able to  inspect  the  extremity  after  twenty-four  hours,  but  usually  it  is  better 
to  leave  the  dressing  undisturbed  for  a  longer  period.  If  an  abscess  has  formed 
this  is  laid  open,  care  being  taken  not  to  open  into  any  of  the  surrounding 
healthy  tissue,  for  that  is  likely  to  result  in  a  progressive  infection.  Above  all 
things  these  extremities  should  not  be  squeezed  or  manipulated  during  the 
dressing.  We  have  frequently  seen  a  patient's  temperature  rise  several  de- 
grees, and  the  infection  progress  to  a  marked  extent,  after  such  manipulations. 
It  is  painful  to  observe  a  surgeon  inflicting  upon  one  of  these  patients  what 
might  be  termed  diagnostic  massage,  and  forcing  the  septic  material  out  of 
its  fairly  circumscribed  and  consequently  relatively  harmless  position  into  the 
surrounding   tissues. 

Avoid  manipulations.  The  slightest  touch  will  suffice  to  indicate  the  pres- 
ence of  a  circumscribed  accumulation  of  pus,  and  still  one  frequently  observes 
a  physician  squeezing  and  crushing  these  inflamed  tissues  for  several  minutes, 
to  no  purpose  whatever  apparently,  while  he  is  collecting  his  sluggish  thoughts. 
It  is  well  to  remember  that  much  harm  may  be  done  in  this  manner. 

If  there  is  a  deep-seated  abscess  on  the  palmar  side  of  the  hand  it  may 
easily  be  located  by  gently  pressing.  There  is,  however,  no  doubt  but  that  it 
is  much  better  for  the  patient  if  these  abscesses  are  opened  a  little  too  late 
than  a  little  too  early,  as  their  contents  become  much  less  virulent  from  day 
to  day  and  if  the  extremity  is  kept  at  rest  there  will  be  no  progressive  infec- 
tion. 

We  have  recently  looked  up  the  cases  of  severe  infection  of  the  fingers 
which  we  have  treated  in  one  hospital  during  the  past  few  years,  and  find  that 
of  the  entire  number  there  was  not  one  coming  without  an  incision  of  the  palm 
or  forearm  whose  hand  was  disabled  as  a  result  of  the  infection  or  the  treat- 
ment ;  while  among  those  who  had  been  treated  with  small  dressings  of  any 
kind,  without  absolute  rest  and  with  the  palms  or  forearms  incised  before 
entering  the  hospital,  deformed  and  stiff  hands  were  the  rule. 

We  have  made  extensive  observations  with  a  large  number  of  these  cases 
and  have  found  that  the  patients  have  progressed  most  favorably  when  the 
following  antiseptic  solution  was  poured  into  the  dressing  every  one  to  six 
hours : 

Boric  acid,  saturated  solution  in  water six  parts. 

Carbolic  acid,  five  per  cent,  solution one  part. 

Alcohol,  ninety-five  per  cent one  part. 

It  is  astonishing  how  rapidly  a  most  violent,  progressing  infection  of  the 
extremity  will  be  changed  into  a  perfectly  stationary,  harmless  affection  if  the 
two  conditions  mentioned  are  thoroughly  applied. 


SURGERY  OF  THE  EXTREMITIES 


695 


Typical  case.  A  young,  vigorous  farmer,  about  thirty  hours  before  entering  the  hospital, 
had  produced  a  slight  injury  mth  a  dirty  file  while  repairing  some  portion  of  an  old  halter. 
During  this  short  time  the  infection  had  made  such  violent  progress  that  the  patient  seemed 
to  be  in  a  hopeless  state.  He  was  delirious,  his  entire  arm  to  the  shoulder  was  edematous 
and  red,  his  hand  was  severely  swollen,  the  fingers  were  gangrenous  and  this  condition  had 
progressed  upwards  rapidly.  Under  the  treatment  just  described,  the  line  of  demarcation 
formed,  there  was  no  further  progress  in  the  infection  and  the  edema  subsided  rapidly. 
Before  entering  the  hospital  a  small  dressing  had  been  applied.  Until  the  patient  became 
delirious  he  was  permitted  to  walk  about  the  room,  which  he  did  in  the  hope  of  reducing  his 
suffering.  As  usual,  the  pain  subsided  rapidly  after  the  form  of  treatment  before  mentioned 
was  employed,  and  there  was  no  progress  of  the  disease,  although  this  had  been  constant  and 
very  rapid  previously.     We  have  chosen  this  case  for  illustration  because  of  its  great  violence. 

It  is  doubtful  whether  the  antiseptic  solution  in  the  dressing  has  much  influ- 
ence upon  the  infection  directly,  or  whether  the  benefit  comes  entirely  from 
the  effect  of  the  rest  and  the  moist  heat.  Professor  Kahlenberg  has  demon- 
strated positively,  that  within  a  few  minutes  after  the  application  of  moist 
boric  acid  dressings  to  the  skin  the  urine  shows  the  presence  of  the  antiseptic, 
consequently  it  seems  reasonable  to  suppose  that  there  is  direct  benefit  from 
the  use  of  this  remedy. 

The  use  of  electric  light  treatment  to  overcome  pain  and  to  control  infec- 
tion.   In  a  personal  experience  with  septic  infection  of  the  elbow  directly  over 


Electric  Light  Bath  Apparatus  for  an  Extremity. 


the  area  at  which  the  ulnar  nerve  extends  behind  the  elbow-joint  the  pain  was 
so  severe  that  it  seemed  unbearable.  Dry  heat  and  moist  heat  had  no  effect 
upon  the  pain.  When  the  use  of  heat  generated  by  an  electric  light  covered 
by  an  aluminum  cone  reflectin^g  the  light  against  the  infected  area  was  sug- 
gested it  seemed  unlikely  that  this  could  act  differently  from  the  other  forms 
of  heat  that  had  been  employed. 

Upon  applying  the  light,  however,  the  excruciating  pain  disappeared  almost 
at  once  and  since  this  experience  we  have  employed  this  form  of  electric  light 
treatment  in  hundreds  of  cases  of  pain  caused  by  septic  infection  and  quite 
regularly  with  results  that  were  eminently  satisfactory,  not  only  as  regards 
the  relief  of  pain  but  also  because  the  remedy  assists  materially  in  reducing 
the  infection. 

Every  hospital  should  be  supplied  with  this  apparatus  for  the  treatment 
of  the  above  class  of  cases. 


696  SURGERY  OF  THE  EXTREMITIES 

X-ray  burns.  One  of  the  most  distressing  conditions  encountered  in  surgery- 
is  the  X-ray  burn. 

At  first  it  appears  as  a  simple,  slight  irritation  of  the  skin  with  some  redness 
and  induration.  It  may  go  no  further  and  it  may  become  progressively  worse 
until  an  entire  area  of  skin,  together  with  more  or  less  of  the  underlying 
tissue,  has  become  necrotic.  There  seems  to  be  a  condition  of  ischemia  which 
reminds  one  of  the  appearance  of  a  frozen  extremity.  The  destruction  may 
progress  for  weeks  or  months  unless  it  is  stopped  by  appropriate  treatment. 

Snow,  of  New  York  City,  directed  our  attention  to  the  fact  that  exposing 
the  area  occupied  by  an  X-ray  burn  to  strong  electric  light  reflected  by  an 
apparatus  built  on  the  plan  illustrated  will  result  in  very  rapid  and  perfect 
healing. 

If  the  treatment  is  begun  early  the  skin  will  not  become  necrotic ;  if  begun 
late  the  excruciating  pain  will  stop  almost  immediately  and  healing  will  begin 
within  a  few  days  without  any  further  treatment. 

The  light  may  be  used  continuously  or  interruptedly,  but  always  when 
there  is  pain. 

Dry  heat  or  moist  heat  without  the  light  rays  does  not  have  the  same  effect 
either  upon  the  pain  or  the  healing.  There  seems  to  be  penetration  of  the 
electric  light  weaves  which  is  not  common  to  heat  waves  from  other  sources. 
The  treatment  is  easily  applied  and  effective. 

CARBUNCLE 

At  this  point  it  seems  proper  to  discuss  another  localized  infection  so  char- 
acteristic in  its  appearance  as  to  be  classified  separately.  A  circumscribed  area 
of  the  skin,  most  commonly  upon  the  posterior  surface  of  the  neck,  or  upon  the 
back,  becomes  indurated,  then  red  and  later  purple  in  appearance,  then  a  num- 
ber of  small  perforations  occur  upon  its  surface  from  which  a  few  drops  of 
pus  are  discharged.  The  induration  is  usually  one  to  five  cm.  in  diameter,  but 
it  may  extend  from  this  focus  until  a  large  area  has  been  included.  The 
progress  is  through  the  subcutaneous  fat.  It  may  be  uniform  in  every  direc- 
tion or  extend  irregularly,  a  larger  and  larger  portion  of  the  skin  surrounding 
the  original  center  attaining  a  honey-combed  appearance.  The  infected  area 
is  exceedingly  painful  and  the  patient  has  the  general  appearance  of  one  who 
is  severely  ill.  If  the  disease  has  existed  for  a  considerable  period  the  center 
of  the  area  will  contain  a  circumscribed  slough  of  connective  tissue  saturated 
with  pus  opposite  each  one  of  the  small  perforations  in  the  skin.  Unless  vig- 
orous treatment  is  instituted  the  disease  usually  progresses  quite  rapidly  and 
its  progress  is  especially  favored  by  motion  in  the  part  or  by  manipulation, 
which  seem  to  force  the  infectious  material  into  the  surrounding  subcutaneous 
connective  tissue.  Often  resistance  has  been  greatly  reduced  by  the  presence 
of  diabetes.  Indeed  in  many  of  these  cases  a  carbuncle  occurs  only  because  of 
the  diabetes,  and  were  it  not  for  this  condition  the  infection  which  has  resulted 
in  a  carbuncle  would  have  caused  but  a  very  slight  circumscribed  superficial 
infection  which  would  have  disappeared  spontaneously  very  quickly,  had  not 
the  tissues  furnished  such  an  excellent  culture  medium  for  the  micro-organisms. 
In  every  instance  it  is  important,  therefore,  to  examine  the  urine  in  order  to 
determine  whether  or  not  the  patient  has  diabetes. 

Operative  technique.  Whenever  it  can  be  done  the  most  satisfactory  form 
of  treatment  consists  in  making  a  crucial  incision  down  to  the  base  of  the  in- 
fected tissue,  dissecting  back  the  four  flaps  of  skin  thus  formed  and  then  re- 


SURGERY  OF  THE  EXTREMITIES  697 

moving  all  of  the  infected  parts.  The  cavity  thus  formed  is  then  carefully 
sponged  with  95  per  cent,  carbolic  acid  and,  after  a  minute,  is  tamponed  with 
gauze  saturated  with  strong  alcohol.  This  dressing  is  renewed  daily  until  the 
wound  is  perfectly  clean,  when  the  edges  of  the  flaps  are  drawn  toward  each 
other  and  the  space  permitted  to  heal  by  granulation,  or  if  the  defect  is  too 
large  it  may  be  covered  with  Thiersch  skin-grafts. 

If  this  radical  operation  cannot  be  performed  in  any  given  case,  one  may 
usually  secure  a  satisfactory  result  by  employing  the  following  method :  From 
five  to  ten  drops  of  a  50  per  cent,  solution  of  95  per  cent,  carbolic  acid  in 
glycerine  are  injected  into  the  base  of  the  indurated  area,  at  points  two 
cm,  apart,  around  the  entire  circumference  of  the  carbuncle.  In  this  manner 
an  entire  circle  is  made  around  the  diseased  area.  It  is  best  to  use  a  hypo- 
dermic needle  and  inject  from  five  to  ten  drops  at  each  point  of  puncture.  The 
fluid ^will  cause  the  albumen  in  the  pus  to  coagulate  and  ooze  out  of  the  per- 
forations in  the  skin  over  the  center  of  the  carbuncle  in  the  form  of  a  white 
fluid.  This  should  be  sponged  away  with  pledgets  of  cotton  saturated  with 
alcohol  so  as  to  prevent  cauterization  of  the  surrounding  skin  with  the  super- 
fluous carbolic  acid.  In  order  to  protect  the  skin  against  this  accident  it  is  well 
to  cover  it  thoroughly  w^ith  vaseline  before  beginning  .the  injections.  After 
the  circle  has  been  completed,  the  surface  is  covered  with  a  thick  layer  of 
gauze  thoroughly  saturated  with  strong  alcohol,  to  dilute  any  carbolic  acid 
which  may  be  discharged  later.  The  patient  is  kept  at  rest  and  the  carbolic 
acid  injections  m.ay  be  repeated  once  or  twice  if  necessary,  but  usually  one 
treatment  will  suffice  or,  if  it  fails,  the  radical  excision  of  the  infected  tissue 
should  be  employed.  If  there  is  marked  improvement  the  wound  is  dressed 
with  moist  antiseptic  dressings  daily  until  healed. 

If  diabetes  is  present  large  quantities  of  distilled  water  should  be  given  in 
order  to  eliminate  the  sugar  as  rapidly  as  possible,  and  the  diet  should  be  care- 
fully regulated.  It  is  important  to  give  these  patients  an  abundance  of  proper 
food  and  prevent  the  absorption  of  products  of  decomposition  from  the  ali- 
mentary canal.     Castor  oil  and  mild  saline  laxatives  are  well  borne. 

VARICOSE  VEINS  OF  THE  LOWER  EXTREMITIES 

Varicose  veins  in  the  lower  extremities  are  accompanied  by  a  great  amount 
of  pain,  and  will  usually  result,  sooner  or  later,  in  the  formation  of  an  ulcer 
of  the  leg,  because  of  the  lack  of  nutrition  in  the  circumscribed  areas  drained 
by  the  lower  end  of  the  saphenous  veins.  If  both  the  superficial  and  the  deep 
veins  are  varicose,  there  will  be  marked  edema  of  the  entire  lower  extremity, 
and  no  operative  treatment  is  of  any  avail.  These  patients  will  progress  most 
comfortably  if  the  bed  is  arranged  so  that  the  lower  extremities  rest  upon  an 
inclined  plane  regularly  at  night.  This  relieves  the  impaired  veins  of  much 
of  their  burden  and  they  have  an  opportunity  to  recuperate  slightly  each  night. 

In  the  morning,  before  the  extremities  are  lowered,  well-fitting  elastic  stock- 
ings should  be  applied,  to  support  the  veins.  It  is  important  that  the  extremi- 
ties be  carefully  measured  so  that  the  stockings  may  fit  accurately,  and  that 
the  measurement  is  taken  after  the  patient  has  rested  in  bed  for  a  number  of 
days  with  the  legs  elevated,  so  that  all  of  the  edema  may  have  disappeared. 
If  there  is  only  cicumscribed  or  superficial  edema,  the  condition  usually  de- 
pends upon  the  incapacity  of  the  valves  in  the  superficial  veins,  namely,  the 
external  or  internal  saphenous,  or  both.    In  this  event,  the  patient  can  usually 


698 


SURGERY  OF  THE  EXTREMITIES 


obtain  permanent  and  perfect  relief  if  these  veins  are  excised,  especially  if  in 
addition  to  such  excision  all  the  superficial  veins  are  severed  transversely. 

Schede  operation.  A  circular  incision  is  made  around  the  leg,  cutting 
through  the  skin,  superficial  fascia  and  all  the  veins  down  to  the  deep  fascia 
a  little  above  the  middle  of  the  leg,  then  uniting  the  wound  in  the  skin  by 
means  of  sutures  throughout.  There  is  considerable  danger  of  having  a  con- 
striction of  the  scar  following  this  operation,  but  this  danger  can  be  avoided 
by  carrying  the  incision  through  the  skin  and  superficial  fascia  and  the  veins 
down  to  the  deep  fascia,  through  the  circumference,  with  the  exception  of  an 
inch  opposite  the  spine  of  the  tibia,  and  the  same  distance  on  the  posterior 
surface  of  the  leg.    The  superficial  fascia  and  veins  between  the  skin  and  the 


External  aspect.     Varicose  veins  of  the  leg  accompanied  with  ulcer  on  external  aspect  of 
ankle.    Treated  by  excision  of  long  saphenous  vein;  Schede  operation  and  Nussbaum  operation. 


^    f. 


Internal  aspect.  Note  that  this  Schede  incision  is  placed  midway  between  the  two  on 
the  outer  side,  and  that  no  incision  extends  completely  around  the  leg.  An  Unna's  paste  cast 
was  applied  after  removing  the  stitches. 

Surgical  Treatment  of  Varicose  Veins. 

deep  fascia  at  these  points  may  be  severed  by  passing  a  knife  under  the  skin 
with  the  cutting  edge  downward.  This  will  prevent  a  circular  scar  extending 
entirely  around  the  leg.  A  further  improvement  in  this  operation  consists  in 
making  the  incision  obliquely  instead  of  exactly  at  right  angles  with  the  leg. 
The  operation  is  performed  with  a  constrictor  applied  to  the  thigh,  so  there 
can  be  no  hemorrhage  during  the  work,  and  it  will  not  be  necessary  to  ligate 
any  of  the  veins,  the  constrictor  not  being  removed  until  the  dressing  has  been 
applied  and  the  patient  placed  in  bed,  with  the  extremity  elevated. 

EXCISION  OF  THE  SAPHENOUS  VEINS 


The  internal  saphenous  vein  is  more  commonly  affected  than  the  external. 
To  determine  the  extent  of  the  excision  the  patient  should  be  permitted  to 


SUHGEKY  OF  THE  EXTEEI\nTIES  699 

stand  erect  for  a  few  minutes  and  the  point  noted  to  which  the  vein  is  enlarged. 
It  should  then  be  excised  to  a  distance  several  inches  above  this  point. 

Technique.  The  extremity  is  elevated  and  held  for  several  minutes  until 
the  veins  have  become  entirely  empty.  Then  an  Esmarch  constrictor  is  applied 
to  the  thigh  high  up  and  vein  laid  bare  by  an  incision  extending  over  the 
entire  distance  through  which  it  is  enlarged.  The  uppermost  end  is  then  dis- 
sected free,  grasped  with  two  pairs  of  hemostatic  forceps  and  cut  between,  and 
the  upper  end  ligated.  The  vein  is  then  dissected  out  downward  throughout 
the  desired  length ;  the  larger  communicating  branches  being  caught  with  for- 
ceps and  ligated,  or  they  may  be  left  open  with  safety. 

In  many  cases  after  the  vein  has  been  severed  at  its  upper  portion  and 
ligated,  the  entire  enlarged  vein  can  be  removed  through  two  or  three  small 
button-hole  incisions,  by  using  a  vein  stripper  as  devised  by  C.  H.  Mayo.  This 
avoids  making  a  long  cut.  In  cases  in  which  the  A'ein  is  not  very  tortuous  this 
method  is  very  satisfactory. 

After  the  entire  vein  has  been  excised  the  wound  is  closed  and  a  large  anti- 
septic dressing  applied,  so  that  the  pressure  upon  the  wound  will  be  uniform 
and  mild.  The  constrictor  is  not  removed  until  the  patient  has  been  placed 
in  bed  with  the  extremity  elevated.  The  extremity  should  be  left  in  an  ele- 
vated position  for  at  least  one  week  after  the  operation,  and  then  it  should 
be  slowly  lowered.  At  the  end  of  the  second.,  week  a  soft  flannel  bandage  may 
be  applied  and  the  patient  permitted  to  be  about.  It  is  well  for  the  patient  to 
wear  a  flannel  bandage,  applied  every  morning,  for  a  number  of  months,  before 
the  foot  is  lowered.  It  is  also  wise  for  him  to  sleep  with  the  extremity  elevated 
upon  an  inclined  plane  so  as  to  relieve  the  deep  veins  during  the  night. 

Unna's  paste  cast.  In  mild  cases  of  varicose  veins  of  the  extremities  the 
following  treatment,  if  applied  for  a  period  of  from  three  months  to  one  year, 
will  almost  always  give  great  relief,  and  it  will  frequently  strengthen  the  veins 
to  such  an  extent  that  the  patient  may  remain  entirely  well  for  years. 

The  limb  should  first  be  kept  in  an  elevated  position  for  several  days  and 
nights  in  order  to  empty  the  veins  thoroughly  and  remove  any  edema  that  may 
be  present.  The  following  mixture  is  then  prepared.  Place  four  parts  by 
weight  of  plate  gelatin  in  ten  parts  of  distilled  water,  permit  this  to  stand  over 
night,  then  place  in  a  water  bath,  heat  in  this  way,  stir  constantly  until  dis- 
solved; add  ten  parts  of  glycerine  while  hot,  then  add  four  parts  of  impalpable 
oxide  of  zinc  powder.     Stir  constantly. 

Apply  ten  thicknesses  of  gauze  about  the  foot,  covering  the  toes  to  protect 
them  against  contact  with  the  cast.  Apply  a  similar  amount  of  gauze  aroimd 
the  upper  end  of  the  proposed  cast. 

If  this  precaution  is  not  taken  the  skin  will  be  severely  irritated  at  the 
upper  and  lower  ends  of  the  cast.  It  is  consequently  also  important  not  to 
apply  any  of  the  paste  beyond  the  margin  of  these  protecting  gauze  bands. 
The  surface  of  the  foot  and  leg  between  these  two  bands  is  now  thickly  painted 
with  the  hot  paste  by  means  of  an  ordinary  large  painter's  brush.  The  sur- 
face is  then  covered  with  a  thin  gauze  roller  bandage  two  inches  wide,  great 
care  being  taken  to  apply  the  bandage  smoothly.  These  bandages  are  now 
continuously  covered  with  the  hot  paste  until  the  leg  has  been  covered  with 
about  four  layers  of  the  saturated  gauze  roller  bandages.  The  cast  remains 
elastic  after  it  is  dry.  It  may  be  worn  from  one  to  four  months,  when  it 
should  be  replaced. 

The  same  method  is  indicated  in  the  after-treatment  of  cases  that  have 
been  operated  for  the  relief  of  varicose  veins,  or  varicose  ulcer. 


700 


SURGERY  OF  THE  EXTREMITIES 


Varicose  ulcer  of  twelve  years'  duration.     Treated  l)y  dressings  and  elevation  of  leg  for 
two  weeks,  followed  by  skin-grafting.     Two  skin-grafts  shown  in  position. 


' 

"^^^^^' 

.  mH 

.  ,,          ^^fflip- 

^1^^*       "^ 

-HE^.- 

The  same  ulcer,  showing  wire  netting  to  protect  the  new  skin. 


Unna's  paste  cast  applied  to  support  the  varicose  veins  of  the  leg. 


SURGEEY  OF  THE  EXTREMITIES  701 

VARICOSE  ULCERS 

If  the  veins  have  been  varicose  for  quite  a  time,  especially  in  patients 
working  hard,  or  in  those  who  are  likely  to  subject  their  extremities  to  trauma- 
tism, an  ulcer  is  apt  to  form  on  the  lower  extremity.  So  long  as  the  patient 
remains  upon  his  feet,  and  so  long  as  nothing  is  done  to  relieve  the  condition 
in  the  veins,  such  an  ulcer  is  unlikely  to  improve.  If,  on  the  other  hand,  the 
patient  is  placed  in  bed  with  the  lower  extremities  elevated  upon  an  inclined 
plane,  the  pressure  removed  from  the  veins  and  consequently  the  return  cir- 
culation favored,  the  area  occupied  by  the  ulcer  becomes  better  nourished  and 
healing  is  promptly  favored.  The  same  is  true  after  excision  of  the  varicose 
veins,  and  the  circular  incision  through  all  of  the  superficial  veins,  provided 
the  ulcer  has  not  existed  too  long  and  has  not  become  of  such  size  that  its 
covering  with  epithelium  is  impossible.  The  floor  of  the  ulcer  will  then  become 
composed  of  a  mass  of  hard,  connective  tissue,  the  result  of  an  attempt  at 
cicatrization  of  the  ulcer,  and  it  is  difficult  for  epidermis  to  grow  over  this 
surface. 

In  these  advanced  cases  it  is  better  to  excise  this  connective  tissue  and 
cover  the  entire  surface  with  Thiersch's  skin-grafts,  at  the  same  time  that 
operation  is  performed  for  the  relief  of  varicose  veins.  By  the  time  the  wound 
of  the  latter  operation  is  healed  the  skin-grafts  will  have  firmly  adhered  to 
the  raw  surface  and  the  patient  at  once  relieved  of  the  ulcer. 

Nussbaum  operation.  In  varicose  vein  cases  with  an  ulcer  of  long  standing, 
we  frequently  do  the  operation  devised  by  Nussbaum,  in  addition  to  making 
an  excision  of  the  internal  saphenous  vein  and  doing  the  Schede  operation. 
This  consists  in  making  a  circular  incision  around  the  ulcer  area  about  one 
inch  from  its  edge,  extending  down  through  the  skin  and  superficial  fascia 
to  the  deep  fascia,  then  suturing  the  wound  throughout.  This  cuts  off  all  of 
the  veins  going  to  and  from  the  ulcer  area.  If  the  ulcer  is  large  it  can  be  skin- 
grafted,  as  suggested  above,  after  the  Nussbaum  operation  has  been  completed. 
In  cases  of  small  varicose  ulcer,  in  which  the  superficial  veins  are  not  prom- 
inent, we  frequently  just  make  the  Nussbaum  operation,  without  excision  of 
the  internal  saphenous  vein.    This  operation  has  proven  very  satisfactory. 

SKIN-GRAFTING 

This  procedure  is  indicated  wherever  a  surface  is  deprived  of  a  sufficient 
amount  of  skin  to  make  a  spontaneous  covering  impossible,  or  in  cases  in  which 
it  would  require  too  great  a  period  of  time,  or  in  which  the  skin  formed  in 
this  manner  would  not  be  sufficiently  substantial.  It  is  also  indicated  after 
the  removal  of  tumors  in  which  so  much  of  the  overlying  skin  has  to  be  re- 
moved as  to  make  it  impossible  to  bring  the  edges  properly  together.  In  these 
instances  the  operation  of  skin-grafting  may  be  carried  out  at  once,  provided 
the  hemorrhage  be  sufficiently  stopped  at  the  time  of  the  operation.  The  same 
is  true  after  the  excision  of  troublesome  scars  after  burns  or  injuries. 

Technique.    The  success  of  the  operation  depends  upon, 

1.  Absolutely  aseptic  conditions. 

2.  Securing  a  bloodless  surface  on  which  to  graft  the  skin. 

3.  The  accurate  application  of  the  skin-grafts :  and 

4.  The  fact  that  the  grafts  have  not  been  injured  by  contact  with  any  anti- 
septic solution  between  the  time  of  their  removal  from  the  normal  skin  and 
that  of  their  application  to  the  raw  surface. 

The  area  from  which  the  skin  is  to  be  removed  should  be  prepared  as  care- 
fully as  though  any  other  operation  were  to  be  done.  The  most  convenient 
place  from  which  to  obtain  skin  is  the  outer  surface  of  the  thigh.     The  skin 


702  SURGERY  OF  THE  EXTREMITIES 

is  removed  by  means  of  a  sharp  razor,  preferably  with  a  wide  blade,  held 
parallel  with  the  surface  of  the  extremity,  being  permitted  to  slide  upon  the 
thigh.  The  thickness  of  skin  to  be  removed  is  regulated  carefully  by  the 
method  of  holding  the  razor.  The  skin  should  be  stretched  so  as  to  make  it 
as  tense  as  possible.  Then  a  layer  should  be  shaved  ofp  by  means  of  a  saw- 
ing motion.  This  layer  should  contain  the  epidermis  and  a  thin  portion  con- 
taining the  tops  of  the  papillae. 

The  portion  cut  is  permitted  to  fold  itself  upon  the  surface  of  the  razor 
until  a  sufficiently  long  strip  has  been  removed  to  extend  across  the  ulcer  or 
raw  surface  to  be  covered.  This  may  be  calculated  very  easily,  so  that  each 
successive  strip  will  extend  quite  across  the  part.  Neither  the  skin  nor  razor, 
nor  the  surface  to  be  grafted  upon,  should  be  wet.  If  this  precaution  is  taken 
union  between  the  surfaces  will  take  place  almost  instantly. 


^' jmiBmmmmmmmmmk 


Protection  of  Skin  Grafts. 

Shows  how  skin  grafts  are  protected  by  a  wire  mesh  frame  which  allows  of  dry  healing, 
no  dressings  to  disturb  the  grafts,  and  they  can  be  inspected  frequently. 

A  large  raw  surface  following  complete  mammectomy  covered  with  skin  grafts,  three 
weeks  after  grafts  were  applied. 

The  plan  practised  so  long  of  covering  the  razor,  the  skin  and  the  portion 
to  be  grafted  with  normal  salt  solution  reduces  the  chances  of  rapid  and  per- 
fect union. 

In  order  to  spread  the  graft  over  the  area  to  be  covered  most  conveniently 
the  sharp  edge  of  the  razor  should  be  placed  in  contact  with  this  surface,  and 
while  the  graft  is  being  pulled  off  this  edge  by  means  of  a  needle  fastened  in 
a  pair  of  hemostatic  forceps  the  razor  is  slowly  moved  across  the  surface.  In 
such  manner  the  graft  will  be  almost  perfectly  spread  without  any  further 
manipulation.  The  edges  may  be  still  further  adjusted  by  means  of  a  pair 
of  needles  fastened  in  hemostatic  forceps.  It  is  well  to  let  the  delicate  edges 
of  these  grafts  overlap  a  little.  After  the  entire  surface  has  been  covered 
with  a  series  of  these  sections  it  is  protected  by  the  application  of  a  network 
of  rubber  tissue  strips  from  two  to  three  millimeters  in  width.  These  will 
at  once  protect  the  underlying  skin-grafts  and  at  the  same  time  make  it  pos- 
sible  for  drainage  to  take  place  between  these  pieces.  A  dressing  of  sterilized 
gauze  is  placed  over  these  strips  and  held  in  position  by  means  of  rubber 


SURGERY  OF  THE  EXTREMITIES  703 

adhesive  straps.  A  thick  layer  of  absorbent  cotton  is  then  put  over  all  and 
held  in  position  by  means  of  a  soft  roller  bandage. 

Of  late  we  have  used  a  method  of  protecting  skin-grafts  which  is  far 
superior  to  any  previously  employed.  After  the  skin-grafts  have  been  applied, 
a  wire  mesh  ''basket"  is  fitted  so  that  no  part  of  it  touches  the  wound,  and  its 
edges  are  well  padded  with  gauze.  In  this  position  the  "basket"  is  held  in 
place  by  adhesive  strips,  first  passing  it  through  a  flame,  in  order  to  sterilize 
it.  A  layer  of  sterile  gauze  is  then  placed  over  the  wire  and  a  gauze  bandage 
holds  all  in  position.  The  grafts  may  be  inspected  from  time  to  time  without 
disturbing  them. 

After-treatment.  The  wound  is  not  disturbed  for  one  week,  when  the  dress- 
ings are  thoroughly  moistened  and  removed  without  disturbing  the  grafts.  It 
is  important  that  the  dressings  be  not  pulled  upon  as  at  this  time  the  attach- 
ment between  the  grafts  and  the  raw  surface  is  still  very  slight.  If  the  dress- 
ing is  performed  carelessly  enough  harm  may  be  done  to  destroy  a  portion  of 
the  new  skin. 

After  the  dressing  has  been  removed,  together  with  the  rubber  protective 
strips,  a  similar  toilet  to  the  one  first  applied  should  be  used  and  at  the  end  of 
a  second  week,  when  this  is  again  removed,  the  wound  is  usually  found  per- 
fectly healed.  If  this  plan  is  carried  out  it  will  not  be  possible  to  distinguish, 
after  the  wound  has  healed,  the  different  grafts  applied;  the  surface  being 
perfectly  smooth,  there  will  be  no  traction  thereon,  and  it  will  be  sufficiently 
firm  to  bear  the  ordinary  abuses  to  which  the  skin  is  exposed. 

NERVE  SUTURE 

It  is  generally  accepted  that  the  regenerative  sheath  of  a  nerve  is  the 
neurilemma,  and  that  all  nerves  which  are  provided  with  a  neurilemma  are 
capable  of  repair  under  favorable  conditions,  but  that  those  without  a  neuri- 
lemma are  incapable  of  repair  under  any  circumstances.  The  nerves  of  special 
sense  are  not  provided  with  a  neurilemma,  so  consequently  they  have  no  power 
of  regeneration,  no  matter  how  carefully  they  may  be  adjusted. 

For  some  unknown  reason  sensory  nerves  seem  to  regenerate  much  more 
rapidly  and  under  less  favorable  conditions  than  do  motor  nerves. 

Nerve  suturing  should  be  employed  where  a  nerve  is  severed  accidentally 
during  an  operation ;  where  a  portion  of  nerve  had  to  be  excised,  together  with 
some  malignant  growth ;  where  a  portion  of  nerve  has  been  severed  or  de- 
stroyed by  traumatism;  and  occasionally  in  cases  in  which  a  nerve  has  been 
caught  between  the  ends  of  a  fractured  bone  and  destroyed  by  the  pressure 
due  to  the  formation  of  callus. 

If  the  nerve  be  sutured  immediately  after  being  severed  the  operation 
simply  consists  in  adjusting  the  nerve  ends  and  then  applying  a  sufficient 
number  of  fine  catgut  sutures  to  hold  them  in  perfect  coaptation.  It  does  not 
matter  whether  these  sutures  are  passed  through  the  trunk  of  the  nerve  or 
simply  include  the  sheath.  The  important  point  is  to  have  the  ends  of  the 
nerve  carefully  approximated.  It  is  well  to  adjust  over  the  line  of  suture 
in  the  nerve  a  convenient  piece  of  fascia,  which  can  be  obtained  in  the  wound 
by  means  of  a  few  fine  catgut  sutures. 

If  a  portion  of  nerve  has  been  destroyed  hy  some  traumatism  the  difficulty 
is  easily  managed,  as  one  of  the  principal  conditions  to  be  obtained  in  order 
to  secure  success  is  the  absence  of  tension  upon  the  nerve  ends.  In  cases  in 
which  the  ends  cannot  be  adjusted  absolutely  without  tension  the  distance 
between  them  should  be  bridged  over  in  the  following  manner: 

Technique.  The  nerve  ends  are  cut  off  squarely;  then  a  very  fine  catgut 
suture  is  passed  back  and  forth  between  the  divided  extremities,  each  time 


704  SURGERY  OF  THE  EXTREMITIES  . 

passing  through  the  end  at  a  little  distance  from  the  previous  point  of  per- 
foration until  a  bundle  of  catgut  has  been  produced  approximately  the  size  of 
the  nerve  being  sutured.  This  should  be  applied  so  that  there  is  absolutely  no 
tension  upon  the  sutures,  which  should  lie  loose  between  the  two  nerve  ends. 
When  a  sufficient  amount  of  this  catgut  has  been  thus  arranged  the  ends 
are  tied  and  the  entire  bundle  of  catgut,  together  with  the  two  nerve  ends, 
is  covered  by  reflecting  a  flap  of  fascia  over  them  and  attaching  them  to  some 
of  the  soft  tissues  beyond  by  means  of  a  few  fine  catgut  sutures.  By  this 
method  we  have  secured  perfect  functional  results  where  as  much  as  three 
inches  of  the  ulnar  nerve  had  been  destroyed  by  a  gunshot  wound,  and  in  a 
number  of  other  cases  we  have  had  equally  satisfactory  results  with  this  form 
of  grafting  nerves  by  means  of  intervening  catgut  sutures.  If  the  nerve  has 
been  severed  for  a  period  of  time  the  conditions  are  still  further  complicated 
because  the  ends  of  the  nerves  are  now  covered  with  connective  tissue,  and  in 
order  to  secure  satisfactory  functional  results  it  will  be  necessary  to  absolutely 
remove  all  of  this  connective  tissue.  The  tendency  in  these  operations  is  al- 
ways to  cut  away  too  little  of  such  tissue  in  order  not  to  increase  the  distance 
between  the  ends  too  greatly.  Many  failures  are  undoubtedly  due  to  this 
disposition. 

With  section  through  a  relatively  healthy  nerve  and  a  distance  of  an  inch 
or  more  between  the  ends  the  chances  for  a  satisfactory  functional  result  are 
much  greater  than  with  the  ends  directly  sutured  together,  and  wherein  all 
of  the  connective  tissue  which  has  resulted  from  the  healing  of  the  nerve  stump 
has  not  been  removed. 

We  would,  therefore,  emphasize  the  importance  of  cutting  away  a  suffi- 
cient amount  in  cases  in  which  nerve  grafting  is  practised  a  considerable  time 
after  the  nerve  has  been  severed.  Here  again  it  is  important  to  bear  in  mind 
that  a  condition  of  tension  is  the  worst  possible  one  to  be  obtained  in  nerve 
suturing. 

The  surgeon  will  often  encounter  no  small  amount  of  difficulty  in  finding: 
the  nerve  ends  directly,  if  the  operation  is  performed  some  time  after  the 
injury  has  occurred,  for  the  traumatism  itself  and  the  subsequent  healing 
has  usually  disturbed  the  relations  to  such  an  extent  that  the  nerve  cannot 
readily  be  discovered  by  searching  for  it  in  its  normal  anatomical  position. 

The  proximal  nerve  end  is  usually  considerably  enlarged  and  may,  there- 
fore, be  found  more  easily,  as  it  can  be  felt  through  the  other  tissues.  This 
is  not  the  case  with  the  distal  nerve  end,  however,  which  is  rarely  enlarged 
.at  all.  It  is  always  wise  in  these  cases,  if  the  nerve  end  is  not  found  at  once, 
to  locate  the  nerve  in  its  normal  position  at  some  distance  from  the  point  of 
injury  and  then  follow  it  down  to  where  it  has  been  severed.  It  is  not  neces- 
sary to  loosen  the  nerve  entirely  from  its  attachments  in  doing  this.  All  that 
needs  to  be  done  is  to  free  its  superficial  surface  and  follow  this  doM^n  to  the 
end. 

If  the  nerve  has  been  included  in  callus,  resulting  in  a  paralysis  of  the 
portion  beyond  the  seat  of  the  fracture,  and  was  not  injured  directly  at  the 
time  of  the  fracture,  then  the  paralvsis  will  have  come  on  slowly  and  not  have 
existed  directly  after  the  time  of  the  injury.  For  this  reason  it  is  important 
to  obtain  a  perfect  history,  for  it  frequently  happens  that  a  nerve  is  sur- 
rounded by  callus,  and  as  this  increases  in  firmness  the  pressure  upon  the  nerve 
results  in  a  paralysis.  If  this  nerve  is  laid  bare  and  the  callus  chiseled  away 
the  nerve  may  be  released  from  its  grasp,  and  unless  it  has  been  held  in  the 
callus  for  a  lengthened  period  its  function  will  be  restored.  In  order  to  pre- 
vent again  becominsr  compressed  in  the  callus  it  should  be  carried  to  some  dis- 
tance from  the  original  point  of  incarceration  and  surrounded  by  some  of  the 
soft  tissues.     The  same  precaution  should  be  taken  if  the  nerve  has  been  en- 


SURGERY  OF  THE  EXTREMITIES  705 

tirely  severed  and  the  ends  caught  in  the  callus.  Too  much  stress  cannot  be 
laid  upon  the  importance  of  carefully  observing  cases  of  paralysis  following 
fracture,  asmuch  greater  success  follows  an  early  rather  than  a  late  operation. 

Prog-nosis.  Where  the  nerve  is  sutured  directly  at  the  time  of  the  injury, 
both  the  immediate  and  the  remote  results  are  good.  Sensation  may  return 
within  a  few  hours  after  the  operation,  and  motion  will  begin  to  return  within 
a  few  weeks,  and  may  be  perfect  within  three  months.  If  the  operation  be 
performed  several  weeks  or  months  after  the  injury,  then  sensation  may  return 
within  a  short  time,  but  unless  the  action  of  the  muscles  is  maintained  by 
means  of  electricity  or  massage  atrophy  is  likely  to  occur  and  the  patient 
will  recover  but  slowly  from  the  paralysis  of  motion.  In  some  instances  the 
recover}^  from  paralysis  of  motion  may  occur  as  late  as  one  or  two  years 
after  the  operation,  and  the  functional  result  may  continue  to  improve  for  a 
very  long  time  thereafter.  The  prognosis  is  relatively  much  better  the  nearer 
the  terminal  end  of  the  nerve  the  injury  occurs ;  consequently  the  suturing 
of  one  of  the  large  nerves  does  not  give  nearly  so  good  a  prognosis  as  the 
smaller  ones. 

Transplantation  of  nerves.  During  the  past  few  years  considerable  progress 
has  been  made  in  transplanting  nerves,  or  portions  of  nerves,  to  supply  other 
nerves  which  have  lost  a  portion  of  their  substance  as  the  result  of  trauma- 
tism or  operation.  This  plan  has  recently  been  extended  to  the  transplanting 
of  a  portion  of  a  normal  nerve  into  the  edge  of  a  nerve  which  has  become  use- 
less as  the  result  of  central  disturbance,  such  as  poliomyelitis.  It  is  claimed 
that  in  this  manner  the  portion  of  the  nerve  which  remains  intact  will  carry 
on  the  function  of  the  entire  nerve,  while  the  portion  attached  to  the  useless 
nerve  will  in  time  restore  the  latter  to  a  fair  amount  of  activity. 

Recently  the  loss  of  function  of  a  severed  facial  nerve  has  been  restored 
by  anastomosing  it  with  the  spinal  accessory  nerve.  Several  operators  have 
reported  excellent  results  from  this  operation.  The  important  points  about 
the  operation  are  to  secure  a  good  end-to-end  anastomosis  of  the  nerves  with- 
out any  tension,  and  then  to  imbed  the  anastomosed  portion  of  the  nerves  in 
the  belly  of  the  digastric  muscle  or  sterno-hyoid  muscle,  so  as  to  avoid  unneces- 
sary scar  tissue  about  the  anastomosis. 

TENDON  SUTURES 

If  a  tendon  is  severed  and  sutured  immediately  the  result  is  almost  invari- 
ably satisfactory,  provided  the  wound  remains  aseptic.  It  does  not  matter 
what  method  of  suturing  be  employed  so  long  as  the  tendon  ends  are  in  apposi- 
tion. It  is,  however,  best  to  insert  the  sutures  in  such  a  manner  that  they  can- 
not readily  split  the  tendon  end  longitudinally.  This  is  best  accomplished  by 
passing  the  suture  into  the  tendon  end,  then  out  through  one  side,  then  pass- 
ing it  a  short  distance  across  the  tendon,  and  then  into  the  tendon  again. 

If  a  considerable  portion  of  a  tendon  has  been  destroyed  the  ends  may  be 
united  in  the  manner  described  for  uniting  nerve  ends  at  a  distance.  The 
functional  results  in  these  cases  are  surprisingly  good.  We  have  repeatedly 
united  tendon  ends  more  than  six  inches  apart  with  perfect  functional  results 
where  theoretically  one  could  expect  nothing  but  failure.  It  is,  however,  of 
the  greatest  importance  to  avoid  tension. 

In  cases  in  which  a  tendon  is  contracted  it  may  be  lengthened  by  split- 
ting longitudinally  in  halves,  then  cutting  off  one  of  these  segments  in  one 
direction  at  the  end  of  this  longitudinal  incision  and  the  other  segment  in  the 
opposite  direction  at  the  other  end,  then  stretching  out  the  tendon  and  unit- 
ing the  two  segments  so  produced.    In  this  way  any  desired  amount,  which  does 

not  exceed  double  the  original  length,  may  be  very  easily  obtained.     The  ten- 
is  '  ...  ..-■-- 


706  SURGEKY  OF  THE  EXTREMITIES 

don  very  quickly  becomes  firm  and  the  functional  results  are  highly  satis- 
factory. 

If  the  operation  is  performed  immediately  after  a  tendon  has  been  severed 
the  o:reatest  difficulty  is  encountered  in  finding  the  tendon  ends,  which  usually 
retract  a  greater  or  less  distance  within  their  sheaths.  If  a  closed  pair  of 
forceps  be  passed  up  through  the  sheath  until  it  reaches  the  point  at  which 
the  tendon  end  can  be  felt  and  then  opened,  this  end  can  usually  be  caught  and 
brought  down.  If  this  cannot  be  done  an  incision  may  be  made  opposite  the 
point  to  which  the  tendon  has  retracted  and  a  stitch  may  be  passed  through 
the  tendon  end  and  threaded  in  the  eye  of  an  old-fashioned  probe,  and  this 
carried  through  the  sheath  of  the  tendon,  and  then  by  drawing  on  the  suture 
the  tendon  end  may  be  brought  down  and  united  to  the  distal  end.  If  the  end 
cannot  be  located  the  sheath  may  be  split  until  it  is  reached.  It  is  then 
brought  down  and  united  and  the  sheath  sutured  over  it  with  fine  catgut 


^5CL 


Opekatiox  for  Lexgthekixg  Contracted  Tendons. 

To  the  left  is  shown  the  incision,  which  may  be  lengthened  to  any  desired  extent.  To  the 
right  is  shown  the  method  of  suturing  the  lengthened  tendon. 

sutures.  Usually  this  does  not  result  in  any  adhesions  between  the  sheath 
and  the  tendon  unless  the  wound  becomes  infected. 

In  applying  sutures  to  tendons  tension  should  be  avoided  and  the  sutures 
should  never  be  tied  tightly  enough  to  cause  pressure-necrosis,  as  tendon  is  a 
tissue  not  well  supplied  M'ith  blood,  and  consequenth'  easily  injured  in  this 
manner. 

Healing  may  be  further  favored  in  applying  the  dressing  with  the  extrem- 
it}'  in  the  most  favorable  position  for  obtaining  a  relaxation  of  the  muscles 
belonging  to  the  tendons  which  have  been  sutured. 

TENDON  TRANSPLANTATION 

In  patients  suffering  from  infantile  or  spastic  paralysis  it  is  often  possible 
to  obtain  remarkably  satisfactory  functional  results  by  transplanting  the 
tendon  of  a  muscle  not  affected  by  the  paralysis  to  the  insertion  of  a  tendon 
of  a  muscle  which  is  affected.  This  may  be  best  illustrated  in  the  talipes 
equino-varus  of  infantile  paralysis,  but  the  same  principle  applies  elsewhere, 


SURGERY  OF  THE  EXTREMITIES  707 

Here  the  equinus  position  may  be  overcome  by  lengthening  the  tendo 
achilles,  T\-hile  the  deformity  due  to  turning  in  of  the  foot  is  corrected  by 
transplanting  the  lower  attachment  of  the  tendon  of  the  tibialis  anticus  muscle 
from  the  inner  to  the  outer  side  of  the  foot.  An  incision  2  cm.  in  length  is 
made  just  below  the  anterior  annular  ligament  of  the  ankle,  directly  over  the 
tendon  of  the  tibialis  anticus  muscle.  A  blunt  hook  is  passed  around  this  for 
the  purpose  of  making  traction.  Then  a  similar  incision  is  made  over  the 
attachment  of  the  tendon  to  the  inner  surface  of  the  cuneiform  bone.  The 
tendon  is  then  loosened  from  its  lower  attachment,  which  may  be  facilitated 
by  drawing  gently  upon  the  blunt  hook.  A  third  incision  is  then  made  over 
the  point  of  insertion  of  the  peroneus  brevis  to  the  outer  surface  of  the  fifth 
metatarsal  bone.  The  space  between  the  first  and  third  incision  is  then 
tunneled  with  a  pair  of  blunt  forceps,  and  the  end  of  the  tendon  drawn  througfh 
this  channel  and  carefully  attached  to  the  tendon  of  the  peroneus  longus  by 
means  of  fine  chromicized  catgut  sutures  near  the  point  of  attachment  of  the 
latter  muscle,  or  to  the  point  of  attachment  of  the  peroneus  brevis.  The 
three  wounds  are  then  sutured  and  the  foot  dressed  in  a  plaster-of-Paris  cast 
at  a  little  less  than  a  right  angle.  The  splint  is  worn  for  three  months.  In 
our  experience  this  operation  has  given  very  satisfactory  results. 

It  is,  of  course,  important  that  the  muscle  to  which  tendon  is  to  be  trans- 
planted be  in  a  fairly  normal  functional  condition. 

It  is  unnecessary  to  carry  the  application  of  this  principle  through  the 
various  operations  in  which  it  may  be  employed  as  any  one  sufficiently  familiar 
with  anatomy  may  select  from  the  muscles  those  best  suited  for  the  purpose 
of  substitution  for  those  which  are  completely  or  partly  paralyzed. 

TUBERCULOSIS  OF  THE  JOINTS 

This  condition  is  characterized  by  its  slow  beginning,  by  its  usual  limita- 
tion to  one  .joint,  by  the  tendency  to  fixation  of  the  joint,  and,  later,  by  atrophy 
of  the  muscles,  both  above  and  below  the  affected  part.  Its  location  is  often 
determined  by  a  traumatism,  although  this  cannot  always  be  established,  and 
wliere  there  is  a  history  of  injury  the  surgeon  cannot  always  exclude  the  pos- 
sibility of  coincidence. 

Usually  it  is  secondary  to  tuberculosis  of  the  respiratory  or  alimentary 
tract,  the  tonsils  or  the  lymph  glands,  the  bacilli  having  been  carried  to  the 
vicinity  of  the  epiphyseal  line  of  the  bones  or  to  the  joint  surfaces  by  the 
blood-stream.  It  is  therefore  of  the  greatest  importance  that  the  surgeon's 
attention  be  primarily  directed  toward  the  improvement  of  the  patient's 
general  health,  which  can  be  best  accomplished  by  bettering  his  hygienic 
surroundings,  nutrition  and  habits  of  life ;  and  by  administering  tonics  and 
concentrated  foods  and  some  form  of  creosote.  Above  all  things  he  should  not 
be  permitted  to  continue  living  under  the  conditions  which  primarily  gave  rise 
to  his  disease.  These  points  are  of  great  importance,  not  only  in  obtaining  a 
recovery  from  the  immediate  disease,  but  also  for  the  purpose  of  securing 
permanency  of  cure.  It  is  virtually  always  necessary  to  change  the  dwelling 
of  these  patients,  if  not  the  climate ;  to  change  their  food,  regulate  their  hours 
of  rest,  and  frequently  their  occupations.  This  having  been  done,  the  treat- 
ment of  the  joint  involved  will  depend  upon  its  location  and  the  extent  to 
which  the  disease  has  progressed ;  but  in  any  case  as  nearly  complete  rest  as 
possible  for  the  joint  is  most  to  be  desired,  especially  if  this  can  be  obtained 
without  confining  the  patient  to  bed.  If  the  disease  is  in  an  incipient  stage, 
rest  alone,  with  the  conditions  described  above,  will  usually  suffice  to  produce 
a  recovery, 


708  SURGERY  OF  THE  EXTREMITIES 

A  light  cast  made  of  plaster-of-Paris,  very  carefully  constructed,  and 
strengthened  by  the  incorporation  of  thin  strips  of  tough  wood,  such  as  are 
used  in  the  manufacture  of  market  baskets,  is  usually  the  most  desirable 
dressing,  unless  the  patient  can  afford  a  similar  dressing  made  of  aluminum. 
The  cast  should  be  applied  over  some  elastic  woven  material,  arranged  in  a 
double  layer,  so  that  any  friction  will  not  be  directly  against  the  skin,  but 
against  the  second  layer,  which  will  remain  free. 

If  the  ankle  or  the  knee-joint  is  involved,  it  is  best  to  draw  two  closely 
fitting  stockings  over  the  extremity. 

The  cast  should  be  worn  for  a  number  of  months  after  the  joint  is  appar- 
ently perfectly  well. 

HIP-JOINT  TUBERCULOSIS 

In  the  hip-joint  the  treatment  by  fixation  with  a  plaster-of-Paris  cast  should 
be  supplemented  by  weight-and-puUey  extension,  to  be  applied  at  night,  for 
a  period  of  at  least  two  years  after  the  joint  has  apparently  fully  recovered, 
as  this  seems  to  prevent  recurrence,  deformity,  to  increase  the  comfort  of 
these  patients,  and  to  remind  them  of  the  necessity  of  avoiding  traumatism  for 
a  considerable  time.  The  extension  is  made  by  applying  a  strip  of  rubber 
adhesive  plaster  from  eight  to  twelve  centimeters  in  width,  to  the  inner,  and 
outer  surface  of  the  entire  thigh  and  leg,  and  holding  them  in  place  by  a  roller 
bandage.  These  plaster  strips  are  attached  to  the  cord  which  passes  over  the 
pullej'  to  the  weight,  by  means  of  two  cords  attached  to  a  cross-piece  of  wood 
eight  to  fifteen  centimeters  in  length.  The  lower  end  of  the  bed  should  be 
elevated  from  ten  to  twenty  centimeters,  in  order  to  secure  counter-extension 
from  the  weight  of  the  body.  The  weight  employed  should  be  from  one-tenth 
to  one-fifth  of  the  weight  of  the  body,  the  correct  amount  being  determined 
by  the  comfort  of  the  patient.  It  is  well  to  begin  with  a  light  weight  and 
increase  gradually. 

If  rest  and  hygienic  measures  alone  are  not  sufficient  to  obtain  a  cure, 
which  may  usually  be  determined  by  an  increase  in  the  pain,  or  that  the 
swelling  did  not  subside,  or  that  a  point  of  fluctuation  appears  in  the  vicinity 
of  the  joint,  then  it  will  become  necessary  to  open  the  joint  and  remove  the 
diseased  tissues,  consisting  of  portions  of  the  capsule,  the  synovial  membrane 
and  cartilage  of  the  joint,  and  in  advanced  cases  usually  some  portion  of 
bone. 

Often  the  radical  operation  may  be  postponed  until  the  treatment  by 
means  of  injection  with  a  mixture  of  iodoform  and  glycerine  has  been  tried. 
This  will  be  described  presently. 

Technique.  In  children,  the  least  possible  amount  of  tissue  should  be 
removed,  as  in  a  great  majority  of  cases  this  will  suffice  to  produce  a  cure 
quite  as  frequently  as  a  more  extensive  operation,  and  because  the  less  tissue 
removed  the  less  will  be  the  deformity,  and  likelihood  of  impairment  in  the 
future  growth  of  the  extremity. 

In  adults  conditions  are  somewhat  different.  Here  an  excision  of  a  suffi- 
cient amount  of  bone  to  insure  anchylosis  is  much  more  likely  to  cause  a 
satisfactory  outcome,  especially  in  the  hip-  and  knee-joints,  both  as  regards 
permanency  of  cure  and  preservation  of  function. 

The  anchylosis  favors  strength  and  the  absence  of  motion  gives  free- 
dom from  pain.  The  permanency  of  cure  depends  to  no  small  degree  upon 
the  fact  that  any  slight  focus  of  infection  which  may  have  been  overlooked 
is  much  less  likely  to  be  kindled  into  activity  if  the  joint  is  placed  perfectly 
at  rest  by  the  anchylosis.  Moreover,  the  excision  of  a  sufficient  amount  of 
bone  to  secure  this  condition  increases  the  likelihood  of  a  complete  remova,! 


SURGERY  OF  THE  EXTREMITIES  709 

of  all  the  diseased  tissue.  After  the  diseased  tissue  has  been  completely 
removed,  the  raw  surfaces  should  all  be  thoroughly  and  repeatedly  swabbed 
with  a  ninety-five  per  cent,  solution  of  carbolic  acid  for  a  period  of  five  min- 
utes, the  superfluous  acid  being  washed  away  with  strong  alcohol.  After 
this,  it  is  well  to  apply  strong,  compound  tincture  of  iodine  to  the  entire 
surface,  and  then  a  ten  per  cent,  solution  of  iodoform  and  glycerine,  after 
which  the  wound  is  to  be  closed  with  deep  sutures  of  catgut  and  superficial 
sutures  of  any  desired  material.  If  any  doubt  exists  as  to  the  aseptic  state  of 
the  joint  when  the  operation  has  been  completed,  it  should  be  freely  drained 
with  rubber  tubes  or  with  iodoform  gauze  passed  transversely  through  the 
articulation.  The  joint  is  then  covered  with  a  large  dressing  and  immobilized 
by  plaster-of-Paris  or  splints. 

All  the  joints  of  the  upper  and  lower  extremities,  with  the  exception  of 
the  shoulder  and  the  hip-joint,  are  operated  after  the  application  of  an  Esmarch 
constrictor.  This  facilitates  the  work  greatly  and  it  is  an  easy  matter  to  avoid 
all  the  important  blood  vessels  during  the  operation,  hence  it  is  not  necessary 
to  remove  the  constrictor  before  suturing  the  wound  and  applying  the  dress- 
ing. If,  however,  there  is  any  fear  in  the  mind  of  the  operator  of  hemorrhage 
later,  it  is  always  best  to  remove  the  constrictor  before  suturing  the  wound, 
carefullj^  grasp  all  bleeding  points  with  artery  forceps  and  ligate  them  before 
closing  the  wound. 

RESECTION  OF  THE  ANKLE-JOINT 

Nothing  has  been  said  concerning  the  operation  itself  in  connection  with 
each  joint,  because  the  typical  operations  outlined  in  every  text-book  are  quite 
as  satisfactory  as  any  we  may  describe,  with  the  exception  of  the  method  for 
resection  of  the  ankle-joint.  The  operation  which  is  here  outlined  is  not  gen- 
erally practised,  but  any  surgeon  who  has  once  tried  this  mode  will  always 
continue  to  employ  it,  as  it  insures  a  most  satisfactory  approach  to  the  diseased 
tissues,  and  the  results  are  likewise  most  satisfactory,  both  as  regards  the  func- 
tional efi^ects  and  permanency  of  cure.  This  is  true  even  in  cases  that  seem 
quite  hopeless  with  any  other  method. 

Technique.  An  incision  is  carried  directly  across  the  anterior  surface  of 
the  ankle  from  malleolus  to  malleolus  through  the  skin,  superficial  and  deep 
fascia  and  the  sheaths  of  all  of  the  tendons  in  the  course  of  the  wound.  Ex- 
ternally the  peroneal  artery  and  nerve  should  be  avoided,  as  well  as  the  ten- 
dons of  the  peroneal  muscles,  which  may  readily  be  drawn  out  of  the  way. 
Internally  the  posterior  tibial  artery  and  nerve  are  protected.  Each  tendon  is 
then  lifted  up  in  the  incision  and  transfixed  with  two  fine  catgut  sutures  from 
one  to  two  centimeters  apart.  These  sutures  are  caught  in  similar  artery  for- 
ceps for  purposes  of  identification,  then  the  tendon  is  cut  transversely  between 
these  sutures.  After  all  the  tendons  have  been  disposed  of  in  like  manner,  the 
joint  is  opened  by  a  free  transverse  incision  and  the  sole  of  the  foot  forced 
back  upon  the  calf  of  the  leg.  In  this  manner  the  entire  joint  is  opened  freely, 
so  that  all  diseased  tissue  may  be  removed.  After  this  has  been  accomplished, 
as  described  in  connection  with  the  treatment  of  tuberculous  joints  in  general, 
the  foot  is  placed  in  position,  the  tendons  carefully  adjusted,  which  may  be 
done  with  great  ease,  because  the  two  sutures  upon  two  corresponding  tendon 
ends  are  fastened  to  hemostatic  forceps  of  the  same  pattern.  Each  tendon  is 
carefully  sutured  and  a  fine  stitch  placed  in  the  fascia  to  cover  the  line  of 
suture  in  the  tendon.  Then  the  skin  is  sutured  over  all.  If  drainage  seems 
necessary,  it  is  applied  through  and  through,  and  even  in  cases  apparently 
requiring  no  drainage,  we  have  usually  passed  a  few  strands  of  catgut  or  silk- 
worm sut  entirely  across  the  foot,  permitting  the  ends  to  protrude  from  the 


710 


SURGERY  OF  THE  EXTREMITIES 


lower  angles  of  the  wound  so  as  to  drain  the  serum  which  may  be  secreted  by 
the  large  surface  during  the  first  few  days.  A  large  dressing  is  applied  and 
the  foot  immobilized  in  a  position  at  a  little  less  than  a  right  angle. 


Excision  of  Ankle  with  Transversk  Anterior  Incision, 

Similar  forceps  being  placed  upon  sutures  inserted  in  the  two  free  ends  of  each  cut  tendon 
for  identification. 

After-treatment.  The  foot  is  elevated  in  order  to  favor  return  circulation. 
If  drainage  has  been  used,  this  is  left  in  place  from  one  to  two  weeks.  The 
dressing  is  not  changed,  unless  indicated  by  the  discharge,  for  a  week  or  ten 
days,  in  order  to  avoid  moving  the  foot,  and  after  that  as  seldom  as  possible  for 
the  same  reason. 


SURGERY  OF  THE  EXTREMITIES  711 

Prognosis.  The  prognosis  is  very  good  after  this  operation.  The  free 
exposure  of  the  surfaces  insures  thoroughness,  and  consequently  the  cure  is 
usually  permanent.  The  ankylosis  of  the  surfaces  immediately  in  the  field  of 
operation  does  not  interfere  with  movement  because  the  tarso-metatarsal  joints 
will  supply  the  motion  necessary.  The  tendons  unite  readily  and  act  normally. 
There  is  no  operation  for  the  relief  of  joint  tuberculosis  that  has  given  us 
more  satisfaction  than  this.  With  this  method  it  is  often  possible  to  obtain  a 
useful  foot  in  cases  which  formerly  could  only  be  relieved  by  an  amputation. 

At  the  present  time  it  is  possible  to  obtain  artificial  limbs,  in  case  of  ampu- 
tation at  the  lower  third  of  the  leg,  so  excellent  that  unless  one  can  secure  a 
good  result  after  a  resection  of  the  ankle  an  amputation  is  to  be  preferred. 

TUBERCULOSIS  OF  THE  SHOULDER,  ELBOW  AND  OTHER  LARGE 

JOINTS 

The  shoulder-joint  deserves  some  special  attention,  as  it  is  least  useful  when 
ankylosed,  and  consequently  an  operation  for  the  relief  of  tuberculosis  must 
here  be  performed  in  a  manner  that  will  prevent  ankylosis.  This  may  be 
accomplished  by  stripping  back  the  periosteum  upon  the  shaft  of  the  bone, 
then  cutting  away  the  head,  together  with  two  or  three  centimeters  of  the 
shaft  and  afterwards  covering  the  end  of  the  bone  with  the  periosteum,  which 
has  been  stripped  back,  together  with  some  fascia. 

The  elbow-joint.  In  the  treatment  of  tuberculosis  of  the  elbow- joint,  the 
social  and  economical  condition  of  the  patient  must  be  considered.  An  anky- 
losis at  a  little  less  than  a  right  angle  will  produce  the  most  useful  and  the 
most  powerful  arm  for  a  laboring  man  or  a  mechanic,  but  the  awkward  posi- 
tion will  interfere  with  the  patient's  appearance.  If  one  desires  the  greatest 
amount  of  power  and  usefulness,  the  arm  should  be  dressed  at  a  little  less 
than  a  right  angle.  If  he  is  willing  or  desirous  to  sacrifice  these  qualities  for 
the  sake  of  obtaining  greater  beauty,  a  sufficient  amount  of  bone  should  be 
removed  to  insure  a  movable  joint,  the  ends  of  the  bones  being  again  covered 
with  soft  tissues. 

The  wrist- joint  should  be  dressed  as  nearly  straight  as  possible. 

The  hip-joint.  The  hip  should  be  dressed  with  the  extremity  in  the  ab- 
ducted position,  the  foot  extending  as  nearly  straightforward  as  possible,  both 
inversion  and  eversion  being  avoided.  This  precaution  considerably  over- 
comes the  tendency  to  shortening.  This  position  may  be  secured  by  means  of 
a  plaster-of-Paris  dressing,  or  by  a  w^eight-and-pulley  extension,  combined  with 
the  use  of  a  Hodgen's  splint  with  a  foot-piece  attachment,  which  will  insure 
the  vertical  position  of  the  foot. 

The  knee  should  be  dressed  in  a  slightly  flexed  position,  because  this  secures 
the  greatest  ease  in  walking. 

TUBERCULOSIS  OF  THE  SACROILIAC  JOINT 

Tuberculosis  in  this  joint  is  characterized  by  lameness,  which  at  first  is 
apparent  only  during,  or  more  frequently  the  day  after,  severe  exertion. 

A  misstep  or  a  quick  motion  is  likely  to  give  rise  to  pain.  The  patient 
usually  at  first  imagines  the  pain  to  be  located  in  the  hip,  and  percussion  over 
the  great  trochanter  is  apt  to  give  rise  to  pain.  There  is,  however,  no  suffer- 
ing upon  motion  of  the  hip,  flexion,  extension  and  rotation  being  normal  and 
painless,  unless  the  motion  is  very  sudden  and  sufficiently  violent  to  affect  the 
ilium.  There  is  no  pain  upon  pressure  over  the  hip- joint,  but  pain  is  present 
when  pressure  is  made  over  the  sacro-iliac  articulation,  or  when  compression  of 
the  pelvis  is  made.    There  is  frequently  an  evening  temperature. 

Technique.  The  same  principles  obtain  here  in  the  treatment  of  tubercu- 
losis as  in  the  other  joints.    In  many  hygienic  measures  and  rest  will  result  in 


712  SURGERY  OF  THE  EXTREMITIES 

a  cure.  Injection  with  iodoform  emulsion  gives  very  favorable  results  and 
should  a  sinus  be  formed,  cauterization  frequently  produces  a  cure,  'it  is 
rather  more  difficult  to  obtain  a  thorough  removal  of  all  the  diseased  tissue 
where  the  joint  is  extensively  involved  and  in  which  the  measures  mentioned 
above  have  failed  to  produce  a  cure,  than  in  tuberculosis  of  other  joints. 

In  these  cases  it  becomes  necessary  to  avoid  injuring  the  sciatic  nerve  if 
the  bone  is  so  extensively  diseased  as  to  approach  this  structure.  Our  own 
results  have  been  best  when  we  have  thoroughly  removed  all  of  the  diseased 
bone,  then  treated  the  cavity  with  strong  carbolic  acid,  then  with  alcohol  and 
then  tamponed  with  iodoform  gauze,  which  was  removed  after  a  week,  when 
the  cavity  was  treated  with  strong  tincture  of  iodine  and  sutured  secondarily. 
The  patient  should  be  kept  in  bed  until  the  tissues  have  become  firm* 
because  motion  is  likely  to  disturb  the  newly-formed  tissues  and  cause  a' 
recurrence. 

After-treatment  in  cases  that  do  not  heal  primarily.  Should  the  wound  not 
heal  primaril}^,  the  sinuses  may  be  stimulated  by  the  injection  of  strong  com- 
pound tincture  of  iodine,  ninety-five  per  cent,  carbolic  acid,  lollowed  with 
strong  alcohol,  or  two  to  ten  per  cent,  solutions  of  nitrate  of  silver  in  water. 
It  has  been  claimed  that  these  sinuses  will  heal  much  more  rapidly  if  ex- 
posed daily  to  the  influence  of  the  X-ray  for  a  period  of  fifteen  minutes  at  a 
distance  of  twelve  to  fifteen  centimeters.  We  have  not  tried  this  method  in  a 
sufficient  number  of  cases  to  be  entitled  to  an  opinion,  as  the  possibility  of 
coincidence  must  not  be  overlooked. 

In  a  number  of  instances  we  have  seen  rapid  and  permanent  healing  after 
touching  these  sinuses  thoroughly  with  the  actual  cautery,  the  point  of  the 
cautery  being  introduced  into  the  sinus,  permitting  the  heat  to  radiate  to 
the  surrounding  tissues.  This  is  much  better  than  to  attempt  to  touch  all  of  the 
infected  parts  directly.  A  rod  of  iron  the  size  of  a  lead-pencil,  heated  to  red 
heat  m  a  gas  or  alcohol  flame,  or  in  a  coal  fire,  or  a  tinsmith's  heater,  serves 
this  purpose  admirably.  Before  introducing  this  rod  into  a  sinus,  the  direction 
and  depth  of  the  latter  should  always  be  determined  by  means  of  a  probe,  in 
order  that  the  cautery  may  be  readily  introduced  in  a  manner  to  insure  the 
cauterization  of  the  sinus  throughout  its  course  without  destroving  healthv 
tissue. 

MIXED  INFECTION  IN  TUBERCULOUS  BONE  AND  JOINT  DISEASES 

So  long  as  the  entire  infection  is  due  to  the  bacillus  of  tuberculosis,  the 
progress  of  the  disease  is  slow,  and  except  where  the  pressure,  within  the'cap- 
sule  of  the  joint,  gives  rise  to  severe  pain,  the  patient  usually  does  not  give  the 
impression  of  being  verv-  ill,  unless  the  affection  is  complicated  with  other 
troubles,  such  as  tuberculosis  of  the  lungs.  If,  however,  the  disease  becomes 
complicated  by  infection  of  the  abscess  with  other  pathogenic  micro-organisms, 
the  condition  of  the  patient  at  once  becomes  much  more  serious.  He  acquires 
the  appearance  of  one  suffering  from  a  degree  of  sepsis,  depending  upon  the 
form  and  extent  of  the  infection,  and  his  general  state  becomes  rapidly  more 
grave,  usually  first  recognized  by  the  characteristic  hectic  flush. 

It  is  a  singular  fact  Avhich  has  been  constantly  demonstrated  clinically,  that 
a  tuberculous  abscess  may  open  spontaneously  and  discharge  through  a  sinus 
for  weeks,  months,  or  even  years,  without  becoming  infected  with  other  patho- 
genic micro-organisms,  while  a  similar  abscess  opened  by  an  incision  may 
become  infected  almost  at  once.  This  is  of  great  practical  importance,  as  it 
illustrates  the  point  that  by  a  simple  incision  the  surgeon  may  in  a  moment 
change  a  harmless  tuberculous  abscess  into  an  exceedingly  harmful  mixed 
infection. 


SURGERY  OF  THE  EXTREMITIES  713 

In  any  case,  then,  in  which  it  seems  impossible  to  remove  all  the  tuberculous 
infection  and  change  a  tuberculous  abscess  into  a  clean  wound,  it  seems  im- 
portant to  follow  a  method  which  removes  the  tuberculous  pus  from  the  body 
without  substituting  for  it  a  worse  condition.  This  may  be  accomplished  by 
lifting  up  a  fold  of  the  adjoining  healthy  skin  for  a  distance  of  three  to  five 
centmieters  and  piercing  the  abscess  with  a  trocar  two  or  three  millimeters  in 
diameter,  permitting  the  tuberculous  pus  to  escape,  and  then  injecting  the 
cavity  with  a  ten  per  cent,  solution  of  iodoform  in  glycerine,  sterilized.  ^(The 
iodoform  should  be  put  into  an  open  bottle  with  a  cotton  stopper  and"  placed 
m  a  water  bath.  The  water  should  be  permitted  to  boil  around  the  bottle  for 
one  hour.    This  will  liberate  enough  free  iodine  to  accomplish  the  sterilization.) 

lODOFORM-GLYCERINE  INJECTION  OF  TUBERCULOUS  JOINTS 

Differing  opinions.  There  is  much  difference  of  opinion  regarding  the 
value  of  lodoform-glycerine  mixtures  injected  into  the  cavity  of  "tuberculous 
joints.  Its  advocates  show  a  large  number  of  perfect  and  permanent  recoveries 
following  this  form  of  treatment,  while  its  opponents  claim  that  all  of  these 
cases  belong  to  a  class  which  would  have  healed  with  the  same  results  in  about 
the  same  time  had  they  been  treated  with  rest  and  ordinary  hvgienic  measures 
Both  the  advocates  and  the  opponents  of  this  form  of  treatment  represent 
some  of  the  ablest  and  most  experienced  surgeons,  and  we  are  not  prepared  to 
decide  which  faction  is  right,  although  our  own  experience  is  strongly  in  favor 
of  this  method  in  the  early  treatment  of  tuberculosis  in  all  joints," except  the 
hip.  There  are,  however,  several  points  in  the  technique  which  should  be 
rigorously  obej^ed : 

Rules  of  procedure.  1.  The  trocar  should  never  be  plunged  directly  into  a 
joint,  but  always  obliquely  underneath  a  fold  of  skin,  so  that  a  valveNvill  be 
formed  whenthe  instrument  is  withdrawn,  which  will  prevent  the  infection  of 
the  joint  cavity  with  pathogenic  micro-organisms. 

2.  The  amount  of  manipulation  should  be  limited  so  as  to  prevent  the 
opening  of  lymph  spaces  through  which  secondary  infection  might  occur. 

3.  The  amount  of  pressure  employed  in  injecting  the  solution  should  be 
moderate  m  order  to  avoid  rupturing  the  capsule  of  the  joint  and  forcing  the 
fluid,  together  with  tuberculous  contents  of  the  joint,  into  the  tissues 
surrounding. 

4.  If  the  treatment  does  not  result  in  distinct  benefit  to  the  patient  after 
five  or  six  applications,  from  one  to  two  weeks  apart,  it  should  be  abandoned. 

5.  The  patient's  general  and  hygienic  surroundings  must  be  improved  to 
a  favorable  standard. 

6.  As  much  as  possible  of  the  fluid  contained  in  the  joint  should  be  with- 
drawn before  the  injection  is  made. 

7.  Except  in  the  shoulder  and  sacro-iliac  joints,  an  Esmarch  constrictor 
should  be  applied  before  the  joint  is  tapped,  and  left  in  place  until  a  large 
dressing  has  been  fitted  and  held  in  position  by  a  snug  bandage,  which  will 
prevent  hemorrhage  into  the  joint. 

_  This  last  precaution  is  not  generally  employed,  but  we  are  confident  that  it 
is  of  distinct  benefit. 

In  applying  the  constrictor  for  this  purpose  the  same  precaution  should  be 
taken  against  injuring  the  large  nerves  as  in  other  operations.  A  large  rubber 
tube  or  a  broad  rubber  bandage  should  be  used  in  preference  to  the  narrow 
rubber  band  usually  employed.  If  a  small  rubber  tube  or  a  narrow  band  is 
used,  the  extremity  should  first  be  protected  by  wrapping  with  a  towel,  folded 
upon  itself  at  least  four  times. 

In  inserting  the  trocar  into  the  various  joints,  aside  from  carefully  securing 
a  valve  formation  of  the  canal,  the  surgeon  must  avoid  injuring  'important 


714  SURGERY  OF  THE  EXTREMITIES 

anatomic  structures  in  the  vicinity  of  the  joint,  and  the  point  of  the  trocar 
must  be  directed  so  that  it  will  not  injure  any  joint  surface. 

In  the  smaller  joints  a  very  small  amount  of  the  solution  may  suffice,  the 
quantity  depending  upon  the  tension  caused  by  the  tiuid  injected,  which  should 
never  be  sufficiently  great  to  endanger  the  capsule  or  produce  severe  pain.  In 
the  wrist- joint  the  introduction  of  the  fine  trocar  used  is  usually  not  followed 
by  the  evacuation  of  any  tiuid,  and  here  the  injection  of  two  to  four  cubic 
centimeters  will  often  be  followed  by  perfect  results. 

In  the  knee-joint  it  is  often  possible  to  withdraw  several  ounces  of  fluid, 
and  in  these  cases  it  is  safe  to  inject  as  high  as  thirty  or  forty  cubic  centi- 
meters of  the  iodoform-glycerine  solution. 

In  the  treatment  of  psoas  and  iliac  abscesses  much  larger  quantities  of 
tuberculous  pus  are  frequently  withdrawn  through  the  trocar,  and  it  is  safe 
to  inject  from  thirty  to  fifty  cubic  centimeters  of  a  ten  per  cent,  solution  of 
iodoform  in  glycerine. 

To  prevent  too  great  tension  in  injecting  this  solution  into  tuberculous 
joints,  it  is  well  to  attach  a  soft  rubber  tube  to  the  trocar  with  one  end,  and 
to  a  glass  syringe  holding  thirty  cubic  centimeters  with  the  other,  and  then 
pour  the  solution  into  the  glass  syringe  and  introduce  the  plunger  after  the 
rubber  tube  and  the  trocar  have  become  filled  with  the  solution  spontaneously. 

In  forcing  in  the  plunger,  if  the  pressure  becomes  too  great,  the  intervening 
rubber  tube  will  dilate  before  a  sufficient  amount  of  pressure  has  been  exerted 
to  injure  the  capsule  of  the  joint.  In  injecting  the  large  joints  a  large  trocar 
is  used,  but  in  the  smaller  joints  the  trocar  should  be  just  large  enough  to 
permit  the  transmission  of  the  iodoform  mixture. 

Until  the  pain  has  subsided  the  patient  should  be  kept  at  rest,  then  a  mod- 
erate amount  of  exercise  is  useful.  The  injection  is  repeated  every  one  to  two 
weeks  at  first,  and  less  frequently  later. 

New  preparations.  More  recently  we  have  frequently  used  two  mixtures 
in  place  of  the  above  one  of  iodoform  in  the  treatment  of  tuberculous  joints 
and  tuberculous  abscesses.  These  mixtures  have  been  used  with  remarkable 
success  by  Professor  Calot,  of  France,  and  we  are  able  to  confirm  his  observa- 
tions. They  are  applied  precisely  like  the  above  iodoform  mixture.  No.  1  is 
used  in  all  cases  in  which  the  joint  contains  liquid  accumulations,  while  No.  2 
is  used  where  the  accumulation  is  of  a  consistency  too  thick  to  he  evacuated 
through  the  trocar,  and  will  have  the  effect  of  liquefying  the  accumulation 
within  a  week  or  two,  when  the  treatment  should  be  continued  with  formula 
No.  L 

Formula  No.  1. 

Iodoform    5    parts. 

Ether    10       ^| 

Guaiacol 2 

Creosote  2 

Sterile  olive  oil 100       " 

Of  this  from  ten  to  twenty  cc.  are  injected  into  tuberculous  joints  or  tuber- 
culous abscess  cavities  after  the  fluid  has  been  evacuated.  This  is  repeated 
once  a  week  at  first  and  less  frequently  later. 

Formula  No.  2. 

Camphor   2   parts. 

Thymol 1 

Of  this  solution  five  cc.  are  injected  once  a  week  until  the  accumulation  in 
the  joint  becomes  liquid. 


SURGERY  OF  THE  EXTREMITEES  715 

Beck's  bismuth  paste.  In  all  eases  in  Tvliicli  operations  are  foUoTved  bv  the 
persistence  of  sinuses  Beck's  bismuth  paste,  consisting  of  one  part  of  arsenic- 
free  subnitrate  of  bismuth  in  two  parts  of  sterile  yellow  vaseline,  should  be 
injected  and  the  external  wound  closed  with  a  gauze  plug.  "We  have  heated 
the  paste  to  one  hundred  and  ten  degrees  F.,  and  thought  that  this  facilitated 
the  thorough  distribution  of  the  substance  to  all  parts  of  the  sinuses,  but 
others  have  applied  it  cold  with  apparently  excellent  results. 

Care  should  be  taken  to  inject  just  enough  to  fill  all  parts  of  the  sinuses, 
but  not  enough  to  catise  a  ruptui-e  of  any  of  the  canals. 

The  injection  should  be  made  daily  at  first  and  less  frequently  later.  In 
case  of  large  cavities  it  is  best  not  to  fill  the  entire  cavity  at  first  until  the 
patient's  tolerance  has  been  established.  In  case  of  poisoning  the  patient's 
gums  will  become  sore  and  later  a  black  line  Avill  develop.  The  patient  will 
feel  depressed.    He  may  or  may  not  have  an  elevation  of  temperature. 

In  these  cases  the  sinuses  or  cavities  should  be  filled  with  olive  oil  heated 
to  one  hundred  and  ten  degrees  F.,  and  drainage  tubes  should  be  inserted  for 
the  free  evacuation  of  the  paste  diluted  with  the  hot  oil.  This  should  be 
repeated  daily  until  the  patient's  condition  has  improved. 

With  fair  caution,  there  is  little  danger  from  poisoning,  but  the  possibility 
should  always  be  remembered. 

Beck's  paste  is  one  of  the  most  valuable  remedies  ever  introduced  into  the 
treatment  of  tubercular  sintises,  and  the  resitlts  obtainable  by  its  careful  use 
are  most  satisfactory. 

When  used  in  large  cavities,  such  as  the  pleural  cavities,  the  paste  should 
contain  a  smaller  proportion  of  bismuth  subnitrate.  In  cavities  of  a  moderate 
size,  we  use  one  part  of  bismuth  with  five  parts  of  yellow  vaseline,  while  in 
very  large  cavities  we  use  one  part  of  bismuth  to  ten  parts  of  vaseline.  We 
have  used  this  remedy  in  the  treatment  of  sinuses  and  abscess  cavities  in 
practically  every  part  of  the  body.  In  sinuses  that  are  left  after  stomach  or 
intestinal  operations,  the  remedy  has  been  especially  satisfactory.  In  these 
cases,  however,  it  is  important  to  bear  in  mind  that  tliere  is  a  slighter  degree 
of  resistance  in  the  walls  of  the  sinuses  and  abscesses  than  in  the  walls  of 
sinuses  leading  down  to  bony  structures,  and  for  that  reason  it  is  important 
to  reduce  the  amount  of  pressure  employed  to  a  minimum. 

Dr.  G.  0.  Switzer,  of  Ludington,  Michigan,  reports  an  exceedingly  interest- 
ing case  of  suppurative  pericarditis  in  which  after  drainage  a  sinus  remained 
which  failed  to  heal  under  ordinary  care,  but  which  healed  rapidly  upon  the 
injection  of  the  cavity  with  bismuth  paste.  We  have  never  had  an  oppor- 
tunity to  use  Beck's  bismuth  paste  in  a  similar  case,  but,  judging  from  the 
progress  this  patient  made  and  from  our  experience  in  the  use  of  the  remedy 
in  sinuses  in  all  other  parts  of  the  body,  we  should  certainly  make  use  of  it 
in  event  of  a  similar  case. 

In  old  sinuses  following  operation  for  empyema  we  have  used  the  remedy 
many  times  with  excellent  results. 

The  following  rules  should  be  observed  in  the  use  of  Beck's  bismuth  paste : 

1st.  Care  should  be  taken  to  use  subnitrate  of  bismuth  which  is  entirely 
free  of  arsenic  and  other  impurities. 

2nd.  It  should  be  thoroughly  mixed  with  the  vaseline  immediately  before 
using,  in  order  that  the  hea^^^  bismuth  may  not  settle  down  to  the  bottom  of 
the  jar  and  be  injected  in  too  marked  a  concentration,  the  contents  of  the 
upper  portion  of  the  jar  containing  little  or  no  bismuth. 

3rd.  A  good  glass  syringe  should  be  used  that  will  deliver  a  definite 
amount  of  the  mixture,  so  that  it  will  be  possible  to  determine  the  amount 
used. 

4th.     The  mixture  should  be  injected  very  slowly,  but  continuously,  in 


c^    _ 


O    OJ 


OJ    o 


"3     !*    rt 


;=y  s 


*H  !; 


CO    H  ►^    Hs  H    CT' 

r+  s  y  f^  jr;  ^ 


■g  2,  ji.  s  '^  ^ 

O    0)    CB  rS  ""^ 


Hh 


j3     -      ft,  J^  CO  - 

O    fB    O  rt-  g  p 

rf-_=    C  ^  g  CD 

IQ  ^  aq  ^  '^  O 

n,  ■';2.  fi,  CD  p 


p  °  p  S  s 


CD 


3  -^    JL 


"hS     C5 


CO 


CO 


CD 


CO  m  ?;  "^ 

m       ►_!  S-  9  CD 

^  -J  O  '-«  "^  5 

^  '^^"  S  '^  S  s 

^  g:  "^  2  •"  ^ 

5;  CD  M  ;:^  g'  g 

S  a  cc  "^  g 

"  u^  ^  i:'  CD 

-  "     CO  C  CD     j- 

:a  S3  rr ::  0  S- 

o  CI  o  H-horo  CO 

a  CD  5  c^  {3"  &i 

'i.  Pj  '-'  CD  CD 


tt  „  2 


!^  r- 

C    <!    ^ 

CD    &,'~<i 

CO     I— 

^  5 

Scr?S 
i-K  CO  ►_; 
p  £i£- 

0    ^ 

S-2^ 

3  ^ 

r1-     _,     hte 

p   2.  ". 

tr  ^D 

P         X 

ac^ 

2  «  0 

g'^. 

2.  ^.  CfQ 

CD 


CD    ^    P    S  ^_ 

P  IT  2  -"  5- 
«=  5  S  S  ^ 

-  ■--'  ^  p  ^ 


CD  VJ 


rf- 


cc    c-^ 


Ka 


2  ^-2 


CD    ^ 


P  6 


CD    O 

CD 

aq  S  o   2. 
P  -      O    p    £3". 

^  2  2  f,cR 


CD 


C5    ^  O    S    CD 


718  SURGERY  OF  THE  EXTREMITIES 

order  to  permit  the  filling  of  all  lateral  sinuses  and  irregularities  connected 
with  the  sinus  through  Avhieh  the  mass  is  injected. 

5th.  If  there  are  several  external  openings,  the  paste  should  be  injocted 
through  one  of  these,  and  as  soon  as  it  appears  at  one  of  the  other  openings, 
this  should  be  closed  and  the  injection  should  be  continued  until  it  appears 
at  the  next  one,  when  this  also  should  be  closed  with  the  finger,  and  so  on, 
until  the  paste  has  successively  appeared  at  all  of  the  openings,  which  will 
indicate  that  it  has  penetrated  all  of  the  bifurcations. 

6th.  The  injection  should  be  made  at  first  every  two  or  three  days,  then, 
as  the  discharge  decreases,  once  a  week.  Later,  once  in  two  weeks,  then  in 
three,  and  then  in  four  weeks,  but  always  with  the  same  care  in  application. 

We  have  applied  this  method  in  hundreds  of  cases  and  consider  it  one  of 
the  best  aids  that  we  have  in  surgery,  but  the  work  must  be  done  by  the 
surgeon  himself,  or  by  an  experienced  assistant,  because  it  must  be  applied 
exactly  right  in  order  to  accomplish  the  desired  end. 

ARTHROPLASTY 

The  mobilization  of  ankylosed  joints  has  become  a  well-established  surgical 
procedure.  The  principle  of  the  operation  consists  in  loosening  the  ankylosed 
bones  or  other  structures  interfering  with  motion  in  the  joint,  removing  any 
bony  or  connective  tissue  which  might  later  interfere  with  free  motion,  and 
then  placing  some  soft  structures  over  the  denuded  joint  or  bony  surfaces  to 
prevent  a  recurrence  of  a  fibrous  or  bony  ankylosis.  In  the  various  experi- 
ments and  operations  covering  a  period  of  many  years  the  interposition  of 
animal  membrane,  such  as  pig's  bladder,  and  the  employment  of  plates  of 
celluloid,  silver,  rubber,  magnesium  foil,  etc.,  has  been  followed  by  varying 
results ;  the  best,  however,  are  obtained  by  the  interposition  of  soft  tissue, 
such  as  fascia,  fat  and  muscle.  Murphy  has  popularized  the  operation  of 
arthroplasty  in  America,  as  Lexer  has  in  Germany.  Murphy  interposed  between 
joint  surfaces  a  pedicle  flap  of  fat  and  fascia,  while  Lexer  interposes  a  free 
flap  of  fat :  and  both  with  apparently  equally  good  results. 

Indications  and  prospects.  The  operation  of  arthroplasty  is  indicated  in 
partial  or  complete  ankylosis  of  the  hip-,  elbow-,  shoulder-  and  knee-joints,  in 
cases  where  the  disability  is  great  enough  to  incapacitate  the  patients  from 
performing  their  regular  duties.  Our  best  results  have  been  obtained  in 
arthroplasties  of  the  hip-joint,  next  the  elbow-,  then  the  shoulder-  and  last  the 
knee-joint.  Good  results  in  the  knee-joint  are  the  most  difficult  to  obtain, 
because  in  order  to  be  movable  and  give  ample  support,  it  has  to  be  mechan- 
ically very  perfect. 

In  arthroplasties  for  ankylosis  following  fractures,  especially  those  of  the 
elbow-joint,  the  operation  is  often  difficult  because  of  the  disturbed  joint  rela- 
tions and  the  often  excessive  callus  formation  about  the  joint. 

In  cases  of  ankylosis  following  the  various  forms  of  arthritis  one  must  not 
attempt  an  arthroplasty  until  it  is  evident  that  the  joint  has  been  free  from 
all  infection  for  a  considerable  time. 

Technique.  It  is  important  that  the  most  rigid  asepsis  be  carried  out  to 
insure  primary  wound  healing  which  is  so  essential  for  success  in  the  operation. 
The  joint  surfaces  are  chiseled  apart  as  nearly  as  possible  in  the  place  of  the 
articulation,  and  bony  prominences  Avhich  might  interfere  with  movements 
of  the  joint  are  chiseled  away.  The  synovial  membrane  is  now  removed  and 
together  with  it  any  connective  tissue  which  might  have  a  tendency  to  lessen 
motion.  The  ends  of  the  bones  are  then  shaped  by  means  of  chisel  or  saw,  to 
correspond  as  nearly  as  possible  to  the  normal  contour  of  the  joint  surfaces.  A 
flap  of  the  muscular  aponeurosis,  together  with  a  considerable  amount  of  fat  is 
dissected  free,  except  its  pedicle  near  the  joint,  and  this  is  interposed  between 


SURGERY  OF  THE  EXTREMITIES  719 

the  new  joint  surfaces,  and  fastened  in  position  by  a. few  catgut  sutures.  The 
joint  should  be  immobilized  for  a  period  of  two  weeks.  At  the  end  of  this 
time  passive  motion  should  be  instituted  and  continued  until  there  is  free  active 
motion. 

THE  TEEATMENT   OF   CRUSHING  INJURIES  OF  THE  EXTREMITIES 

In  the  treatment  of  crushing  injuries  and  lacerated  wounds  of  the  extrem- 
ities, the  point  of  first  importance  lies  in  securing,  as  nearly  as  possible,  aseptic 
conditions. 

It  is  interesting  to  observe  the  marked  difiPerence  in  the  difficulty  one 
experiences  in  obtaining  such  a  result  in  different  classes  of  patients.  For 
persons  who  are  strong  and  healthy,  who  live  in  hygienic  surroundings  and  are 
cleanly  in  their  habits,  it  is  relatively  easy  to  secure  an  aseptic  wound  after  one 
of  these  injuries.  This  is  ordinarily  the  condition  of  railroad  employes,  skilled 
mechanics  in  factories,  men  employed  in  the  iron  mines  in  the  northern  part 
of  this  country,  and  in  farmers ;  but  not  that  of  the  shiftless  who  are  injured 
in  the  streets.  Persons  who  have  been  employed  about  horses  are  more  likely 
to  suffer  from  tetanus  than  others.  This  is  also  true  of  those  who  have  been 
injured  upon  the  highways. 

The  fact  that  mechanics  are  likely  to  have  their  hands  covered  with  oil 
and  particles  of  iron  and  other  metal  does  not  indicate  that  it  will  be  difficult 
to  secure  aseptic  conditions,  as  this  form  of  dirt  is  usually  very  clean  from  a 
surgical  standpoint.  The  oil  contained  in  this  dirt  has  in  itself  an  inhibitory 
effect  upon  the  development  of  micro-organisms. 

If  the  injury  be  severe,  it  is  usually  best  to  anesthetize  the  patient,  because 
this  will  enable  the  surgeon  to  be  more  thorough  in  cleansing  the  wound.  If 
it  is  necessary  to  transport  the  patient  some  distance  to  his  home  or  to  a  hos- 
pital, before  it  is  possible  to  proceed  with  the  cleansing  of  the  wound,  it  is  "best 
to  apply  about  the  extremity  some  dry  sterile  gauze  held  in  place  by  a  com- 
pression bandage. 

Control  of  hemorrhage.  If  the  vessel  can  be  caught  with  hemostatic  for- 
ceps and  ligated,  such  method  is  most  convenient.  If  this  is  not  possible  a 
suture  may  be  passed  around  the  bleeding  point,  and  the  same  ligated.  If 
there  is  simply  oozing  from  a  large  surface,  this  may  be  controlled  by  pressure, 
by  applying  a  gauze  tampon,  to  be  held  in  place  by  a  roller  bandage. 

In  some  instances,  it  is  best  simply  to  keep  the  extremity  in  an  elevated 
position  until  an  elastic  constrictor  can  be  applied,  and  the  wound  disinfected 
and  the  vessel  ligated. 

If  the  palmar  arch  has  been  injured,  and  the  hemorrhage  cannot  be  con- 
trolled by  the  application  of  ligatures  or  hemostatic  forceps,  the  arm  may  be 
elevated  permanently  for  several  days  by  applying  rubber  adhesive  straps  to 
the  forearm,  attaching  these  to  a  cross-piece,  and  to  this  a  cord,  which  passes 
over  a  pulley  suspended  to  the  ceiling,  or  upon  a  frame  to  a  weight,  which  will 
keep  the  extremity  elevated  comfortably.  An  elastic  constrictor  should  never 
be  kept  in  position  for  any  lengthened  period.  It  is  not  safe  for  more  than 
two  or  three  hours  at  a  time,  and  even  this  may  give  rise  to  gangrene  in  some 
cases,  especially  if  the  patient  be  advanced  in  age  and  suffering  from 
endarteritis. 

Disinfection.  Usually  the  disinfection  may  be  thoroughly  accomplished  in 
less  than  half  an  hour. 

If  the  extremity  is  covered  with  black,  oily  dirt,  conjmon  in  mechanics,  it 
it  best  to  first  wash  with  kerosene  or  turpentine  or  gasoline  to  remove  all  the 
oil  and  grease.  All  the  particles  of  dirt  visible  should  be  removed  by  the  use 
of  tissue  forceps  and  the  scalpel,  and  then  the  wound  is  thoroughly  soaked 
with  iodine. 


"^20  SURGERY  OF  THE  EXTREMITIES 

.rr.^^  ^\^  '^'''^''■^  ^^'  ^"^r  covered  with  street  dust,  or  the  patient  has  worked 
among  horses,  it  seems  best  after  applying  strong  compound  tincture  of  iodine 
to  the  entire  surface,  to  rub  iodoform  over  the  whole  part,  because  it  is  claimed 
that  this  treatment  will  prevent  infection  with  the  \etanus  bacillus  and  our 
own  observations  appear  to  confirm  this  theory.  This  class  of  patients  shoukl 
also  be  given  10  cc.  of  anti-tetanus  serum  daily  for  three  days  as  a  further 
prophylaxis  against  the  development  of  tetanus  -runner 

If  a  hand  or  finger,  or  any  other  part  of  an  extremity,  has  been  entirelv 
crushed  oft,  the  remaining  stump  may  be  trimmed  up  at  once,  care  being  taken 
to  sacrifice  as  little  tissue  as  possible;  but  in  the  vast  majority  of  crushing 
injuries  1  is  much  better  for  the  patient  if  only  the  complete  disinfection^! 
accomplished  at  once,  and  the  wound  left  wide  open,  so  that  the  tissues  mav 
have  free  drainage;  this  will  aid  in  preventing  infection,  and  will  favor  the 
recovery  of  tissues  which  seem  hopelessly  damaged  at  the  time  of  the  iniurv 
or  first  examination.  Leaving  the  wound  without  suturing  until  the  tissues 
have  recovered,  also  favors  return  circulation,  because  none  of  the  vessels 
will  then  be  constricted  by  stitches.  Many  times  a  very  useful  skin  flap  will 
become  gangrenous  because  of  the  venous  stasis  resulting  from  the  application 
ot  sutures  directly  after  an  injury  has  occurred,  and  before  the  circulation 
has  become  re-established. 

For  the  reasons  mentioned,  primary  amputation  after  crushing  iniuries 
are  but  rarely  indicated.  ^       jiineb 

It  would,  however,  be  eminently  unsafe  to  leave  these  crushed  tissues 
attached  to  an  extremity  if  the  surgeon  were  careless  in  his  disinfection  but 
it  he  IS  thorough  it  will  result  in  great  benefit  to  the  patient.  If  however 
the  crushed  tissue  is  septic  when  the  patient  comes  under  the  surgeon's  care' 
the  conditions  are  entirely  changed,  for  then  not  only  the  crushed  portion  may 
be  lost,  but  the  infection  may  result  in  a  pyemia  and  the  patient's  life  endan- 
gered. Here  the  plan  of  treatment  should  be  followed  that  was  described  in 
connection  with  septic  infections  of  the  extremities.  After  the  infection  has 
subsided,  an  operation  may  be  performed,  which  will  be  indicated  bv  the  con- 
dition of  the  tissues.  Any  necrotic  portions  will  have  been  removed  from  time 
to  time  while  the  treatment  has  caused  the  septic  infection  to  subside 

If,  however,  the  patient  comes  under  the  surgeon's  care  reasonably  early 
the  danger  of  a  serious  infection  is  very  slight,  provided  the  wound  be  thor- 
oughly disinfected  and  left  wide  open,  as  mentioned  above,  so  that  drainage 
will  be  good,  and  the  return  circulation  favored  bv  elevating  the  extremitv 
and  complete  rest  of  the  extremity  is  enforced,  so  that  any  unavoidable  slight 
mfe^ction  will  not  be  pumped  through  the  lymphatics  in  a  proximal  direction 

In  case  any  pockets  of  local  infection  have  been  formed,  these  should 
be  laid  wide  open,  the  incision  in  each  case  being  carried  parallel  Avith  and 
not  through,  the  important  anatomical  structures  in  the  part  involved    ' 

If  there  are  any  projecting  shreds  of  tissue  that  cannot  possibly  be  utilized 
at  any  future  time,  these  should  be  cut  away,  but  no  tissue,  no  matter  how 
irregular,  which  might  be  used  in  a  plastic  way  should  be  sacrificed  until  it 
IS  known  just  how  much  may  be  saved. 

Too  much  stress  has  been  laid  upon  the  importance  of  the  destruction  of 
large  arteries  or  veins  m  cases  where  it  seemed  wise  to  amputate  at  once, 
under  the  impression  that  gangrene  would  certainlv  occur  from  the  destruc- 
tion of  important  vessels.  There  are  many  instances  in  which  anomalies  have 
existed,  which  could  not  be  determined  at  the  time  of  the  injurv,  or  in  which 
there  has  been  an  unexpected  degree  of  compensatorv  circulation  so  that  an 
extremity  Avhich  was  theoretically  doomed  could  be  saved  entirely,  or  to  a  great 
extent.  It  should,  however,  be  remembered  that  one  mav  take  these  chances 
only  when  it  is  possible  to  so  thoroughly  disinfect  these  wounds  that  we  need 
not  tear  a  dangerous  infection  by  a  waiting,  conservative  plan  of  treatment 


SURGERY  OF  THE  EXTREMITIES  721 

If  we  are  not  competent  to  secure  this  condition,  then  we  must  abide  by  the 
rules  laid  down  at  a  time  when  all  were  equally  handicapped. 

In  case  a  joint  of  considerable  size  has  been  opened,  the  course  of  treat- 
ment to  be  followed  will  depend  largely  upon  the  judgment  of  the  surgeon. 
If  it  seems  likely  from  the  conditions  present  that  an  infection  has  taken 
place,  it  will  be  safest  to  lay  the  joint  widely  open,  being  careful,  however, 
not  to  increase  the  infection,  and  to  disinfect  it  in  the  same  thorough  manner 
as  the  other  tissues.  If  it  seems  fairly  certain  that  no  infection  has  taken  place, 
then  it  will  be  best  to  disinfect  the  wound  in  the  joint  as  described  above, 
and  then  to  close  the  latter  with  a  few  catgut  sutures  and  leave  the  remain- 
ing wound  wide  open.  Too  much  importance  cannot  be  given  the  fact  that  it 
is  an  easy  matter  to  infect  an  open  joint,  and  that  consequently  it  should 
receive  the  first  attention,  and  should  then  be  guarded  carefully  until  the 
remaining  portions  of  the  wound  have  been  thoroughly  asepticized. 

AYliat  has  been  said  of  the  larger  joints  is  true  of  the  metatarsal  and 
phalangeal  joints,  but  it  is  much  less  difficult  to  disinfect  these,  and  conse- 
quently there  is  less  danger  to  the  patient. 

CRUSHING  INJURIES  TO  BONES 

The  large  bones  have  been  considered  in  speaking  of  compound  fractures, 
and  the  same  principles  should  be  carried  out  in  the  treatment  of  crushing 
injuries  of  the  smaller  bones ;  fragments  which  are  entirely  loose  should  be 
removed,  and  irregular  ends  should  be  trimmed  with  bone-cutting  forceps. 
Rough  ends  of  bones  into  which  dirt  has  been  ground  so  thoroughly  that  it 
cannot  be  removed  should  be  trimmed  in  the  same  manner. 

Dressing.  If  it  is  convenient,  the  following  dressing  should  be  employed 
in  wounds  of  the  extremities.  A  saturated  solution  of  boric  acid  in  hot  water, 
to  which  one-third,  by  volume,  of  strong  commercial  alcohol  has  been  added, 
should  be  used  to  moisten  the  aseptic  gauze  which  is  applied  directly  to  the 
wound.  If  there  is  any  reason  for  fearing  tetanus  infection,  a  few  layers 
nearest  the  wound  should  be  composed  of  iodoform  gauze.  Over  this  a  thick 
layer  of  cotton  is  applied,  and  over  all  a  soft  roller  bandage.  If  there  is  an 
increase  in  temperature  the  entire  dressing  should  be  surrounded  by  a  rub- 
ber sheet,  and  from  a  pint  to  a  quart  of  the  above  named  solution  poured  into 
the  dressing  every  three  to  six  hours.  The  quantity  should  be  regulated  by 
the  size  of  the  dressing,  and  the  rapidity  with  which  the  moisture  disappears. 

If  it  is  not  possible  to  apply  a  moist  dressing  the  surface  should  be  lightly 
powdered  with  iodoform.  It  should  then  be  covered  with  iodoform  gauze, 
then  with  sterile  gauze,  then  with  cotton. 

The  dressings  should  be  applied  in  such  manner  that  they  may  be  opened 
without  causing  unnecessary  pain  to  the  patient,  so  that  the  wound  may  be 
inspected  regularly. 

If  there  is  a  tendency  to  the  occurrence  of  necrosis  the  wound  should  be 
inspected  every  day,  but  if  at  the  first  dressing  it  appears  that  the  nutrition 
is  good,  then  it  will  be  best  to  disturb  it  as  seldom  as  possible  until  it  seems 
to  have  recovered  sufficiently  to  make  the  operation  for  final  repair  of  the 
injury  proper.  The  condition  of  the  tissues  will  determine  this.  If  there  are 
small  points  of  necrosed  tissue,  it  is  usually  best  to  wait  until  the  circulation 
in  the  adjoining  structures  has  been  improved  to  such  an  extent  that  no 
further  necrosis  need  be  feared.  If  the  tissues  are  trimmed  too  early,  one  is 
likely  to  remove  portions  that  might  be  utilized  to  advantage  in  repairing 
defects. 

The  final  technique.  In  making  the  final  operation,  it  is  far  more  important 
that  the  ultimate  result  be  satisfactory  than  that  the  appearance  at  the  con- 
clusion of  the  operation  be  pleasing. 


722 


SURGERY  OF  THE  EXTREMITIES 


Case  of  Multiple  Tumors  of  the  Bones. 

Riglil  and  left  knees.  This  is  one  of  a  set  of  stereoscopic  pictures.  Note  the  symmetrical 
spines  and  ' '  mushroom ' '  bony  growths  projecting  upward  from  the  femur  and  downwards 
from  thfc  tibia.     The  whole  knee-joint  is  enlarged  and  deformed. 


724  SURGERY  OF  THE  EXTREMITIES 

Too  often  a  portion  of  an  extremity  is  sacrificed  in  order  to  obtain  a  hand- 
some stump.  The  absence  of  skin  from  one-half  or,  in  some  instances,  even 
three-fourths  of  the  portion  of  the  extremity  involved,  no  longer  makes  an 
amputation  imperative,  because  the  surface  can  be  covered  with  skin-grafts, 
and  if  this  is  done  before  the  wound  has  existed  long  enough  to  produce  a 
great  amount  of  cicatricial  tissue  the  extremity  frequently  becomes  very  use- 
ful. The  fact  that  nerves  have  been  destroyed  for  a  distance  not  to  exceed 
ten  or  twelve  centimeters  does  not  make  an  amputation  imperative.  Neither 
is  this  the  case  if  tendons  to  the  same  length  have  been  destroyed,  because 
these  structures  may  be  grafted,  and  although  this  is  not  always  successful  it 
so  frequently  results  in  a  satisfactory  functional  result  that  it  is  quite  worth 
while  to  make  the  attempt. 

In  covering  large  surfaces  with  skin-grafts,  the  method  which  has  been 
described  should  be  carefully  followed,  for  it  will  result  in  a  substantial, 
pliable,  soft  and  durable  covering,  instead  of  the  thin,  shiny,  adherent  skin 
one  encounters  so  frequently  in  cases  that  have  been  grafted  by  different 
methods. 

The  old  rule  of  preserving  the  head  of  the  metatarsal  bone  invariably,  if 
at  all  possible,  and  the  head  of  the  metacarpal  bone  in  men  who  work  with 
their  hands,  should  be  borne  in  mind.  It  is  wise  to  do  this  even  if  there  is 
not  sufficient  skin  to  cover  the  bone.  This  precaution  adds  greatly  in  pre- 
serving the  usefulness  of  the  hand  or  foot. 

A  very  small  portion  of  a  hand  or  wrist  is  valuable  to  the  patient,  and 
every  effort  should  be  used  to  preserve  as  much  as  possible  of  the  upper 
extremity. 

In  the  lower  extremity  this  is  also  true,  unless  the  ankle-joint  is  involved 
in  the  injury  and  the  entire  foot  destro.yed.  In  such  case  an  amputation 
through  the  lower  third  of  the  leg  will  enable  the  patient  to  obtain  an  artifi- 
cial limb,  with  which  he  can  walk  comfortably  and  gracefully. 

Above  this  point  it  is  again  necessary  to  save  as  much  of  the  extremity 
as  possible. 

NON-MALIGNANT  TUMORS  OF  THE  BONE  AND  CARTILAGE 

Osteomata  and  enchondromata  occur  most  frequently  from  the  epiphyseal 
lines  of  the  long  bones  but  they  may  arise  from  any  point  on  the  surface  of 
bones. 

In  most  cases  a  history  of  heredity  can  be  traced,  except  in  those  giving 
a  history  of  traumatism.  In  many  cases  both  a  hereditary  tendency  and 
traumatism  can  be  established. 

These  facts  have  long  been  known  to  breeders  of  horses,  who  have  found 
it  necessary  to  discard  stallions  having  exostoses  and  other  abnormal  bony  or 
cartilaginous  developments. 

Ordinarily  it  is  not  important  to  remove  these  growths  because  they  usually 
develop  slowly  and  do  not  degenerate  into  a  malignant  process.  In  case  they 
interfere  with  motion  or  give  rise  to  pain  by  pressing  upon  some  nerve,  or 
give  rise  to  an  unsightly  deformity,  they  should  be  removed.  They  rarely 
recur  and  the  only  precaution  necessary  in  their  removal  is  to  limit  injury  to 
any  of  the  important  structures  in  the  surrounding  areas.  Frequently  the 
nerves  and  blood  vessels  overlying  the  growth  are  much  distorted,  making  it 
necessary  to  be  exceedingly  careful  in  exposing  the  growth,  which  should  then 
be  severed  from  its  attachment  by  means  of  a  sharp  chisel. 

The  following  case  illustrates  one  type  of  non-malignant  bone  tumor  very 
perfectly : 


FAMIL  Y  Tff£E-MUL  TIPLE  BONE  TI/M0H5 

feneration  X  G€Kereitio/{JJ_     Senerat/onlll      Generation  JM        Generaf/o/i^ 

V.  5cki/dr<rn 


tAale 


p  Female 


'Fento/e 


L  S c h'llelren 

rMale 

'Female' 

-Ma/e 

VMale 


Female 


-  Mde 


'^' 


-  F'^male 


.  F^^^l^ 


-  Female' 


y^2  Fema/es 
^Female 
L  f\lo  chilelrf/f 


Male 

r-MalG 

-Male 

.f^etncile 
-Female 

\-i^  Females 

^Ala/e 

r 

,M^le 
•f- 

Mals 

-t 

-/^ale 

-F^f^ol^ 

r-AIale 

-Male 

-Female 
'pemcile 
-Female 

^Male 
t-2  Females 


-tAaie 

-Male 

+ 


\Male 


n 
sj 


both  —'J 


*~H  Females 
y  3  Mcfles 
r  3  [Aa[es 
If^'triale 
rZ  Males 
L  3  /=e'i2ici/es 

VzF^enxales 

L  £  chi/dt-e/i 

i.^  children 

*         -? 

"^i^cWdciren    \F^rricile 

^So  chi/c/ren 
Lj  chilelren 
L  /^o  children 
L.  /^o  chilalt'e/i 

r-Md/e 
IFe^ale 

h  /Vo  children 
\-/\/o  children 
^Female 
\-Mdle 

\IAale 

L  fl/it  ckHdren 


Fema/e         |-  Unmeirnecf 


Plus  (+)  Indicates  That  Bone  Tumors  Were  Present.    Minus   (— )   Means  That 
No  Bone  Tumors  Had  Ever  Been  Discovered. 


726  SURGERY  OF  THE  EXTREMITIES 

The  patient  is  a  farmer,  seventeen  years  of  age,  giving  a  most  interesting  family  history 
which  wili  be  discussed  later. 

Past  liistory.  The  boy  was  a  normal  delivery  and  has  always  been  well  except  for  an 
attack  of  measles  when  a  baby.  When  about  four  years  of  age  his  j^arents  noticed  a  small 
lump  attached  to  the  outer  aspect  of  his  left  ankle  and  apparently  attached  to  the  bone.  This 
tumor  gradually  increased  in  size  until  he  was  eight  years  old,  when  it  had  reached  the  size 
of  half  of  a  small  orange.  The  tumor  later  decreased  in  size  until  at  the  age  of  thirteen 
years  it  was  not  noticeable  except  for  somewuat  greater  contour  of  that  ankle.  There  was 
ttieither  pain  nor  impairment  of  motion  at  any  time  from  the  presence  of  the  mass.  He  has 
never  had  any  severe  injuries. 

Present  liistory.  When  the  patient  was  about  ten  years  old  there  was  first  noticed  a 
small,  hard  lump  on  the  inner  aspect  of  the  middle  of  the  right  arm  as  large  as  a  hen's  egg. 
Until  the  age  of  fourteen  years,  the  father  thinks,  there  was  no  increase  in  size  of  this  lump. 
During  the  past  three  years,  however,  the  tumor  has  steadily  grown  in  size  until  at  present  it 
is  aliout  as  large  as  a  cocoanut  and  causes  his  arm  to  hang  about  45"  from  the  axillary  line. 
He  has  no  pain  or  discomfort  of  any  kind  except  that  the  fingers  and  forearm  become  cold 
easily  when  he  allows  1he  arm  to  hang  down,  especially  when  the  tumor  ]iresses  against  his 
chest  wall.  He  has  free  use  of  all  his  joints  and  otherwise  is  perfectly  well  and  strong. 
Neither  he  nor  his  father  have  ever  noticed  any  other  tumors  on  his  body. 

Physical  examination.  A  well-developed,  stockily  built,  well-nourished  boy  with  good 
color.     Weight,  i;iO  poiuids. 

Htad  and  neck.    Negative. 

Chest.     Heart  and  lungs  negative. 

Abdomen.     Negative. 

Genitalia.     Negative. 

Extremities.  Sight  arm.  There  is  a  large,  irregular,  hard  growth  the  size  of  a  cocoanut 
on  the  inner  aspect  of  the  midtUe  of  the  right  arm  which  is  immovable  with  respect  to  the 
humerus.  The  arm  does  not  hang  perpendicularly  because  of  the  position  of  the  tumor.  The 
brachial  artery  can  he  felt  over  the  surface  of  the  tumor.     The  u])per  arm  is  bowed  outward. 

Left  arm.  There  is  a  small,  smooth  exostosis  on  the  outer  aspect  of  the  left  humerus  3  cm. 
below  the  claviculo-acromial  joint. 

Eight  leg.  Four  growths  each  the  size  of  an  egg  can  be  felt  both  internal  and  external, 
above  and  below  the  knee  joints  of  both  legs,  and  quite  symmetrical  in  both  legs. 

Left  leg.  There  is  another  hard  mass  the  size  of  a  hen  's  egg  on  the  inner  aspect  of  the 
lower  end  of  the  left  tibia.  The  bones  of  the  fingers  and  toes  are  all  short  and  stubby,  and 
attached  to  them  can  be  felt  many  small,  hard  nodules  varyino;  in  size  from  3  mm.  to  1.5  cm. 
in  diameter.  The  joints,  especially  wrists,  knees  and  ankles,  are  uniformly  enlarged.  The  boy 
came  to  the  hospital  because  the  tumor  in  the  arm  was  steadily  growing  in  size  and  limiting 
the  motion. 

Operative  findings  and  procedure.  An  incision  was  made  over  the  middle  of  the  tumor. 
It  was  seen  that  the  liraehial  artery,  veins,  and  nerves  which  normally  are  on  the  inner  side 
of  the  arm  were  all  spread  out  over  the  tumor,  and  the  biceps  muscle  was  crowded  anteriorly 
and  the  triceps  posteriorly  by  the  growth.  The  eireumtlex  artery  and  vein  and  the  musculo- 
spiral  nerve  were  involved.  The  tumor  was  attached  to  the  humerus  by  a  pedicle  5.0  cm.  long 
and  involving  about  one-third  of  the  circumference  of  the  shaft,  and  it  was  at  the  junction 
of  the  jiedicle  and  shaft  that  the  tumor  was  chiseleil  off.  The  major  vessels  and  nerves  were 
kept  aside  with  retractors  and  none  of  them  destroyed  during  the  operation.  The  muscles 
were  allowed  to  come  together  and  fill  in  the  hollow  of  the  bone  and  after  placing  a  rubber- 
tube  drain  in  the  most  dependent  portion  of  the  wound,  the  wound  was  closed. 

Pathology  (Gross).  The  tumor  is  hard  and  cauliflower-like  in  appearance.  It  measures 
13.5  cm.  by  12.5  cm.  by  11  cm.  in  diameters.  The  surface  of  the  whole  tumor  is  covered  with 
a  layer  of  glistening  cartilage  3  to  6  mm.  in  thickness.  Beneath  the  cartilage  is  a  mixture 
of  bony  and  cartilaginous  substance  about  1  cm.  thick.  The  remainder  of  the  tumor  consists 
of  a  framework  of  hard,  bony  material  with  many  spaces  resembling  the  medullary  cavity 
of  bone. 

Microscopical.  The  outer  layer  is  all  cartilage  but  just  internal  to  it  are  deposits  of 
calcium  in  the  matrix  of  the  cartilage.  Deeper  in  the  tumor  the  calcium  deposits  take  on  more 
of  the  appearance  of  bone  in  the  shape  of  lamellge  interspaced  with  dense  cellular  tissue 
resembling  blood  elements. 

Pathological  diagnosis.     Osteoid-chondroma. 

Post-operative  condition.  There  was  no  impairment  of  function  nor  sensation  of  the  right 
hand.  During  the  first  three  days  the  arm  was  swollen  to  nearly  twice  its  normal  diameter. 
On  the  fifth  day  the  rubber  drain  was  removed  and  by  the  eighth  dav.  when  the  superficial 
stitches  were  removed,  the  swelling  had  praeticallv  disappeared.  When  discharged,  three 
weeks  after  operation,  the  boy  had  full  free  use  of  his  arm  and  experienced  no  sensations 
except  tingling  in  the  ends  of  his  third,  fourth  and  fifth  fingers. 

It  is  especially  interesting  to  study  the  family  history  of  this  case  which  is  illustrated 
clearly  by  the  accompanying  family  tree. 

The  patient  is  one  of  a  family  of  eleven  children,  four  females  and  seven  males,  three  of 
whom  have  tumors.  His  two  brothers  and  his  father  have  practically  identical  tumors  about 


SURGERY  OF  THE  EXTREMITIES 


727 


the  knees.  Their  bones  are  all  abnormally  large.  The  patient 's  paternal  grandmother  and  her 
father  had  like  tumors.  The  patient's  paternal  great-grandfather  is  the  first  one  in  the 
family,  to  the  knowledge  of  his  children,  who  had  any  such  tumors.  He  was  a  Hollander  of 
short,  heavy,  stubby  build.  We  were  able  to  trace  fairly  accurate  records  of  all  of  his 
children.  They  are  shown  on  the  chart  in  the  order  in  which  they  were  born — the  first  at 
the  top — and  are  marked  positive  or  negative  to  show  whether  they  did  or  did  not  have  bone 
deformities.  In  the  whole  tree  there  are  113  individuals.  The  tumors  have  grown  in  size 
enough  to  be  uncomfortable  in  only  two  cases,  the  patient  and  one  of  his  cousins,  both  in  the 
fourth  generation.     They  have  never  metastasized  nor  caused  death. 

SUMMARY   OF    CASES 


Males  -|-  25  ^  22.1  per  cent 

Females       -|-     "^  =     ^-^  P^^  ^^^^ 


Males 
Females 

Total 


-  32  =  28.3  per  cent 

-  51  =  45.1  per  cent 

113      100      per  cent 


26.5  per  cent  -\- 


73.4  per  cent  — 


The  above  table  shows  five  times  as  many  males  as  females  positive,  and  that  26.5  per 
cent  of  the  whole  family  are  positive.  The  preponderance  of  males  over  females  is  probably 
accounied  for  by  the  fact  that  the  former  are  much  more  frequently  exposed  to  traumatism. 
As  these  tumors  do  not  begin  to  be  evident  until  the  fifth  or  sixth  year  of  age,  and  since 
about  12  per  cent  of  cases  are  under  this  age,  it  is  probable  that  the  percentage  positive  will 
later  be  higher.  Some  of  the  members  of  the  family  did  not  know  they  had  any  of  the 
tumors  until  a  family  physician  began  systematically  examining  everyone  in  his  locality. 


Elephantiasis  of  the  Arm  Treated  by  Excision  of  the  Eedundant  Tissue. 

AMPUTATIONS 

General  rules.  In  making  amputations,  the  surgeon  should  strive  to  obtain 
a  stump  in  which  the  scar  is  not  adherent  to  the  end  of  the  bone,  so  that  sub- 
sequently there  may  not  be  produced  an  ulcer  at  the  end  of  the  stump,  due  to 
the  fact  that  the  fixed  scar  results  in  constant  pressure  upon  a  given  point. 

The  flaps  should  be  cut  so  that  the  scar  will  be  exposed  to  as  little  pressure 
as  possible.  This  is  accomplished  most  readily  by  making  the  flaps  of  different 
lengths. 

The  sharp  angles  of  the  ends  of  bones  should  be  trimmed  away  for  the 
same  purpose.  In  amputations  through  the  long  bones  a  circular  incision 
should  be  made  through  the  periosteum,  one-half  inch  above  the  point  where 
the  bone_  is  to  be  sawed  off,  and  the  periosteum  should  be  stripped  off  from 
this  portion  so  that  the  free  end  of  the  bone  is  without  periosteal  covering  for 
a  distance  of  one  cm.  The  marrow  of  the  bone  should  be  curetted  away  for 
the  same  distance.    This  will  prevent  the  formation  of  osteophytes. 


728 


SURGERY  OF  THE  EXTREMITIES 


If  the  patient  be  a  laborer,  who  is  compelled  to  walk  on  the  soft  ground 
or  lift  heavy  weights,  it  is  often  desirable  to  obtain  for  him  a  stump  which 
will  support  his  body  directly  upon  its  end.  This  can  be  accomplished  only 
by  constructing  a  covering  layer  of  bone  for  the  end  of  the  stump,  effected 
by  making  the  first  section  a  sufficient  distance  beyond  the  point  at  which 
the  final  section  is  to  be  made,  so  that  when  the  second  section  is  made,  a  plate 
of  the  projecting  portion  can  be  placed  across  the  sawed  end  as  a  covering. 
The  flattest  surface  of  the  bone  is  then  chosen,  and  a  thin  plate  sawed  upward 
to  the  point  at  which  the  ultimate  section  is  to  be  made.  The  periosteal  cov- 
ering of  this  part  is  left  in  place,  but  the  periosteum  of  the  remaining  portion 
of  the  bone  is  stripped  upward  and  protected  while  this  portion  of  the  bone 
is  being  sawed  off  transversely. 


A.  B. 

X-KAY  Pictures   of  Amputation   Stumps. 
(We  are  indebted  to  Dr.  H.  M.  Lyle,  of  New  York.     J.  A.  M.  A.,  Oct.  3,  1914.) 

Fig.  a.  represents  an  ideal  result  following  amputation  through  a  long  bone  in  which  the 
periosteum  was  removed  completely  for  a  distance  of  1  cm  from  the  end  of  the  bone,  and 
the  marrow  of  the  bone  was  also  curetted  away  for  the  same  distance. 

Fig.  b.  shows  a  very  unsatisfactory  end  of  the  tibia  and  fibula  in  which  exostoses  have 
resulted  from  the  preservation  of  the  periosteum,  the  amputation  having  been  performed  in 
the  usual  manner. 

The  attachment  of  the  plate  which  is  left  standing  will  be  weakened  by  a 
few  strokes  of  the  saw,  care  being  taken  not  to  injure  the  periosteum.  The 
remaining  portion  is  then  broken  and  the  plate  which  has  been  thus  formed 
is  placed  across  the  end  of  the  bone  and  sutured  in  position  by  means  of  a  few 
stitches  of  catgut  passed  through  the  periosteum. 

The  operation  is  completed  in  the  ordinary  way. 

At  the  lower  end  of  the  femur  this  method  can  be  accomplished  by  making 
a  transverse  section  through  the  condyles  and  sawing  off  the  lower  surface  of 
the  patella. 

In  the  upper  extremity,  there  is,  of  course,  never  any  occasion  for  bear- 
ing weight  upon  the  end  of  the  stump,  hence  there  is  no  necessity  for  special 
provision  against  having  the  scar  opposite  the  end  of  the  stump. 


SURGERY  OF  THE  EXTREMITIES  729 

For  this  reason  the  circular  method  has  become  popular  for  amputation  of 
the  upper  extremity. 

It  is  very  important  that  the  flaps  be  cut  long  enough  to  prevent  tension. 
The  larger  nerves  should  be  found,  drawn  doAvn  and  cut  off  two  to  five  centi- 
meters from  the  end  of  the  stump  in  order  to  prevent  their  adhesion  to  the 
scar.  At  the  end  of  a  nerve  of  considerable  size,  it  is  best  to  make  a  Y-shaped 
section,  which  will  permit  the  two  ends  to  fall  together  and  form  a  rounded 
point,  which  has  a  tendency  to  prevent  the  formation  of  an  amputation 
neuroma. 

The  sutures  should  be  drawn  only  tightly  enough  to  secure  coaptation. 

Hemorrhage  should  be  controlled  verj"  accurately,  so  that  the  flaps  will  not 
be  separated  by  blood  clots. 

In  case  the  wound  is  not  perfectly  dry,  or  if  one  cannot  be  absolutely 
certain  that  it  is  aseptic,  drainage  should  be  employed.  This  may  be  accom- 
plished by  the  introduction  of  rubber  drainage  tubes,  or  by  passing  through 
the  wound  a  number  of  strands  of  catgut  or  silkworm  gut. 

The  greatest  care  should  be  exercised  to  prevent  infection,  as  this  favors 
the  formation  of  pressure  neuromata  and  adherent  scars,  both  conditions 
being  sure  to  cause  great  discomfort,  if  not  complete  disability. 

The  stump  should  be  dressed  with  a  sufficient  amount  of  gauze  and  cotton 
to  permit  the  application  of  mild,  uniform  pressure  b}^  means  of  a  soft  roller 
bandage. 

Rest  is  one  of  the  most  important  elements  necessary  for  perfect  healing, 
and  this  may  be  most  readily  attained  by  applying  a  splint  in  every  case  in 
which  it  is  possible.  The  extremity  should  be  elevated,  in  order  to  favor  return 
circulation. 

In  many  of  these  cases,  a  much  better  functional  result  may  be  obtained 
by  simply  trimming  away  the  portions  which  cannot  be  utilized,  after  the 
circulation  in  the  flaps  has  recovered  sufficiently,  and  then  suturing  the  re- 
maining portions  in  the  best  position  possible,  and,  later,  covering  the  remain- 
ing surfaces  with  skin-grafts,  than  if  a  complete  operation  is  performed  at  once. 
It  is  often  possible  to  preserve  a  considerable  portion  of  the  extremity  which 
would  otherwise  have  been  sacrificed.  Many  times  one  or  two  phalanges  of  a 
finger  may  be  saved  in  this  manner,  which  is  a  very  important  matter,  espe- 
cially to  a  workingman. 

SENILE  GANGRENE 

Grades  and  degrees.  Gangrene  not  directly  resulting  from  severe  trauma- 
tism or  septic  infection  is  most  commonly  due  to  a  thrombosis  of  one  or  more 
arteries.  In  aged  persons  this  is  usually  dependent  upon  arterio-sclerosis. 
Its  immediate  location  is  determined  by  an  acute  endarteritis  which  may  be 
the  result  of  a  slight  traumatism  or  exposure  to  cold,  not  sufficient  in  either 
case  to  affect  blood  vessels  in  their  normal  condition. 

The  patient  feels  a  severe  pain,  usually  along  the  course  of  one  of  the 
larger  arteries  in  one  of  his  lower  extremities.  Upon  examination,  the  part 
of  the  extremity  beyond  the  region  of  pain  is  cold  to  the  touch.  For  a  short 
time  after  the  beginning  of  the  difficulty  the  skin  is  white ;  later  it  becomes 
red,  still  later  purple,  and  then  black.  Before  it  becomes  black  numerous 
belbs  usually  form.  The  area  affected  is  at  first  not  circumscribed,  but  there 
is  a  gradual  departure  from  the  normal  appearance  toward  the  proximal  end 
of  the  extremity,  which  changes  into  the  perfectly  black  at  the  distal  end. 
The  latter  condition  may  extend  over  but  a  small  portion  of  one  toe,  or  it  may 
include  one  or  more  of  these  extremities,  or  the  entire  foot,  or  a  large  portion 
of  the  leg. 

Usually  the  morbidity  progresses  upwards  as  the  thrombus  increases  in 


730  SURGERY  OF  THE  EXTREMITIES 

extent.  Many  times  the  circulation  through  the  smaller  branches  of  arteries 
is  increased  because  the  communicating-  branches  are  dilated,  and  then  the 
condition  will  subside  and  portions  which  have  not  yet  become  black,  but 
which  seemed  to  approach  that  state,  may  recover  partly  or  completely.  This 
tendency  may  be  favored  by  keeping  the  extremity  slightly  elevated,  to 
encourage  return  circulation,  and  by  keeping  the  temperature  as  nearly  normal 
as  possible  by  applying  artificial  heat. 

Treatment.  In  the  meantime  the  part  should  be  kept  covered  with  an 
aseptic  dressing,  which  will  prevent  infection  from  without.  It  is  well  to  wash 
the  skin  with  strong  alcohol  each  day,  when  a  fresh  dressing  is  applied. 

Recently  the  iLse  of  Dakin's  antiseptic  solution  has  received  much  atten- 
tion. Large,  moist  dressings  are  applied  as  described  heretofore,  but  enclosed 
in  the  dressing  are  several  small  rubber  tubes  perforated  in  many  places, 
these  tubes  connecting  with  a  larger  tube  which  in  turn  connects  with  a  glass 
chamber  filled  with  chlorazene.  This  chamber  is  suspended  above  the  bed 
and  at  two  hour  intervals  sufficient  warm  solution  is  allowed  to  drip  slowly 
through  the  perforated  tubes  to  saturate  the  dressings.  In  our  experience 
this  treatment  rapidly  cleans  up  even  severe  infections,  and  after  24  to  36 
hours  a  foul,  moist  gangrene  will  have  no  odor.  The  method  has  the  further 
advantage  of  being  inexpensive. 

A  complete  description  of  the  Carrell-Dakin  method  with  formulae  is  given 
in  the  section  on  Military  Surgery. 

For  a  number  of  years  the  opinion  has  prevailed  among  surgeons  that 
it  is  best  to  make  an  amputation  high  up  on  the  extremity  early  in  such  an 
attack,  in  order  to  prevent  the  thrombosis  from  extending  upward  into  the 
common  iliac  artery  and  thence  to  the  same  vessel  on  the  opposite  side.  It 
seems  that  this  theory  cannot  be  supported  by  our  own  experience,  and  con- 
sequently we  advise  the  plan  which  has  been  foimd  most  satisfactory  in  our 
own  work.  It  is  to  be  borne  in  mind,  however,  that  this  is  an  open  question 
as  yet,  and  that  the  plan  here  advised  should  consequently  not  be  accepted  as 
final. 

Our  patients  have  fared  best  when  we  have  kept  the  extremity  as  aseptic 
as  possible  until  the  line  of  demarcation  had  formed.  If  this  occurred  at  any 
point  at  which  an  amputation  would  result  in  a  useful  stump  that  point  was 
chosen  for  the  amputation.  If  a  more  useful  stump  could  be  secured  by  mak- 
ing the  amputation  higher  up  then  that  location  was  selected. 

Amputation.  It  is  often  advisable  to  do  these  amputations  under  local 
anesthesia.  When  the  operator  infiltrates  thoroughly  the  tissues  through  which 
he  cuts,  with  14  per  cent,  cocain  or  i->  per  cent,  novocain,  little  discomfort  is 
caused  the  patient.  Sawing  the  bone  and  stripping  back  the  periosteum  are 
not  painful.  These  patients  are  given  14  gr-  of  morphine  and  /loo  gr-  atropine 
by  hypodermic  one-half  hour  before  the  operation.  This  lessens  their  dis- 
comfort markedly. 

In  making  the  amputation  three  requirements  are  observed : 

1.  The  extremity  is  elevated  in  order  to  make  the  field  of  operation 
bloodless  by  the  aid  of  gravitation.  It  is  kept  in  this  position  throughout  the 
operation,  no  constrictor  of  any  kind  being  employed. 

2.  The  flaps  are  made  ample,  so  that  they  cover  the  end  of  the  stump 
without  the  slightest  amount  of  stretching. 

3.  Xo  sutures  are  employed  for  closing  the  wound,  the  flaps  being  simply 
placed  in  apposition  and  a  large,  rather  loose  dressing  applied  to  hold  them 
in  place. 

The  extremity  is  then  placed  in  a  slightly  elevated  position  to  favor 
return  circulation.  It  will  be  seen  that  these  precautions  are  intended  to 
prevent  impairment  of  the  circulation,  which  is  already  greatly  hampered. 

By  following  these  precautions  the  results  have  been  very  satisfactory. 


SURGERY  OF  THE  EXTREMITIES  731 

After  the  circulation  has  become  thoroughly  established  in  the  flaps  it  is 
safe  to  apply  secondary  sutures  at  any  point  at  which  satisfactory  union 
has  not  taken  place,  or  where  the  coaptation  of  the  skin  has  not  been  effected. 

It  is  important  that  the  patient  be  guarded  against  exposing  himself  in 
the  future  to  the  circumstances  which  acted  as  exciting  causes  of  the  diffi- 
culty. He  should  avoid  traumatism,  cold  and  infection.  His  general  hygienic 
conditions  should  be  improved  and  his  diet  regulated. 

Point  of  amputation  in  cases  of  gangrene.  In  determining  the  point  at 
which  amputation  should  be  made  in  non-diabetic  patients  it  is  important  to 
determine  if  possible  the  exact  point  to  which  the  collateral  circulation  can 
be  depended  upon. 

In  order  to  determine  this  the  sign  of  Moskowicz  seems  to  be  the  most 
dependable.  The  following  plan  is  simple,  safe,  and  easily  employed  under 
all  conditions. 

Apply  a  rubber  band  at  least  5  cm.  wide  around  the  root  of  both  extremi- 
ties simultaneously,  after  both  have  been  emptied  of  blood  by  elevation  into 
a  vertical  position  for  ten  minutes.  A  constrictor  from  a  blood-pressure 
apparatus  serves  admirably  for  this  purpose.  The  constrictor  should  be  ap- 
plied sufficiently  tight  to  completely  obstruct  the  arterial  circulation,  but  not 
so  as  to  cause  injury  from  pressure.  It  should  be'left  in  position  five  to  six 
minutes  then  it  should  be  released  rapidly  and  simultaneously  and  both  ex- 
tremities should  be  placed  in  the  horizontal  position  side  by  side  in  a  good 
light  so  that  the  change  of  color  can  be  accurately  observed.  The  line  of 
amputation  should  be  chosen  just  above  the  line  at  which  the  color  in  the 
diseased  extremity  ceases  to  have  the  normal  pink  appearance  of  the  entire 
extremity,  because  beyond  this  line  the  collateral  circulation  is  defective,  and 
if  an  amputation  were  performed  through  the  tissues  distal  to  this  line,  gan- 
grene of  the  flaps  would  be  inevitable. 

Usually  in  the  lower  extremity  this  line  passes  around  the  limb  in 
an  irregular  form  because  of  the  arterial  distribution,  but  it  is  important  that 
no  part  of  the  flap  extend  below  the  most  proximal  portion  of  the  line.  It  may 
often  be  possible  to  increase  the  length  of  the  stump  considerably  by  forming 
the  flaps  in  a  manner  suggested  by  this  line. 

DIABETIC  GANGRENE 

It  has  been  observed  that  an  operation  upon  a  patient  suffering  from 
diabetic  gangrene,  is  likely  to  be  followed  by  death  within  a  very  few  days, 
in  fact,  usually  within  two  days,  with  the  symptoms  of  diabetic  coma.  This 
fact  has  induced  many  surgeons  to  absolutely  advise  against  surgical  inter- 
vention in  cases  of  gangrene  complicated  by  diabetes.  This  course  will  dis- 
able the  patient  for  a  long  period  of  time,  if  not  permanently,  and  it  exposes 
him  to  the  danger  of  an  intercurrent  septic  infection,  which  is  very  likely  to 
occur  sooner  or  later,  because  the  tissues  in  diabetic  patients  seem  especially 
well  suited  as  culture  media  for  pathogenic  micro-organisms. 

But  in  a  large  proportion  of  these  cases  it  is  not  necessary  to  follow  this 
plan  of  denial  of  surgical  relief,  for  with  proper  precautionary  treatment,  it 
is  possible  to  improve  the  condition  to  such  an  extent  that  they  will  bear 
amputations  almost  as  well  as  patients  suffering  from  uncomplicated  senile 
gangrene. 

The  important  features  of  such  preparatory  treatment  consist  in  giving 
large  quantities  of  distilled  water,  from  two  to  six  quarts  per  day,  until  the 
thirst  has  entirely  disappeared,  which  is  usually  accomplished  within  two 
weeks,  and  after  this  the  quantity  of  distilled  water  is  regulated  by  the 
patient's  desire.  A  moderate  anti-diabetic  diet  is  given — a  diet  which  should 
be  free  from  sugar,  poor  in  starches,  but  in  which  vegetables  may  be  eaten 


732  SURGERY  OF  THE  EXTREMITIES 

very  freely.  The  diet  should  further  contain  considerable  fat,  especially 
olive  oil,  if  it  is  agreeable  to  the  patient.  In  order  to  determine  the  extent 
of  improvement  in  the  patient's  condition,  it  is,  of  course,  necessary  to 
make  a  quantitative  analysis  of  the  urine  from  time  to  time.  In  severe  cases 
the  diet  should  consist  for  the  first  week  of  one  raw  egg  and  one  ounce  of  pure 
olive  oil  at  8  a.  m.,  12  m.  and  4  and  8  p.  m.  exclusively,  except  in  cases  of 
severe  acidosis.  In  these  cases  we  give  i^  oz.  of  pure  olive  oil  at  8,  12,  4 
and  8,  and  one  teaspoonful  of  whiskey  in  14  pint  of  distilled  water  at  6  and 
10  a.  m.  and  at  2,  6  and  10  p.  m. 

When  the  patient's  physical  state  has  improved  satisfactorily,  the  amputa- 
tion should  be  made  precisely  as  in  senile  gangrene,  but  the  greatest  speed 
should  be  exercised  and  the  slightest  possible  amount  of  traumatism  inflicted. 
There  seems  to  be  no  small  danger  from  the  late  effects  of  anesthetics  in  these 
cases,  and  consequently  the  time  of  anesthesia  should  be  reduced  as  much  as 
is  compatible  with  careful  surgical  work.  Here  also  the  use  of  local  anesthesia 
is  often  advisable. 

The  same  precautious  in  after-treatment  should  be  employed  as  following 
the  operation  for  senile  gaugrene,  but  especial  attention  should  be  given  to 
the  diet  of  these  patients  throughout  the  remainder  of  their  lives. 

INGROWN  TOE-NAIL 

The  suffering  brought  about  by  this  condition  is  very  considerable  and 
out  of  proportion  to  the  simple  character  of  the  lesion.  It  is  usually  the 
result  of  tight  shoes  and  the  trimming  of  the  toe-nail  too  close  at  the  corners. 
When  the  first  pain  is  felt  an  attempt  is  made  to  cut  away  the  edge  of  the 
nail  to  prevent  pressure.  Each  time  the  nail  is  usually  cut  a  little  farther 
back  and  the  condition  gradualh'  grows  worse.  The  nail  of  the  great  toe 
should  always  be  cut  straight  across. 

In  the  very  mild  cases  relief  may  be  obtained  by  always  cutting  the  nail 
square  across  and  wearing  properly  fitted  shoes. 

Operative  treatment.  In  some  of  the  very  pronounced  cases  where  both 
edges  of  the  nail  are  involved,  it  may  be  wise  to  remove  the  entire  toe-nail. 
In  the  majority,  however,  it  is  only  necessary  to  remove  about  one-fourth 
of  the  nail.    This  can  easily  be  done  under  local  anesthesia. 

Technique.  A  small  rubber  drainage  tube  used  as  a  constrictor  is  placed 
around  the  base  of  the  great  toe.  A  solution  of  1  to  1000  cocaine  is  now 
injected  subcutaneously  at  the  base  and  side  of  the  nail  and  underneath  the 
nail.  An  incision  is  then  made  down  through  the  nail  and  its  matrix  parallel 
to  its  long  axis,  on  a  line  so  that  about  one. fourth  of  the  nail  may  be  removed. 
This  one-fourth  of  the  nail,  together  with  its  matrix  and  the  granulation 
tissue  along  the  edge,  is  carefully  dissected  away.  A  wedge-shaped  piece  of 
tissue  is  removed  at  the  base  and  just  below  the  lower  end  of  the  nail,  and 
the  defect  closed  with  a  few  horse  hair  stitches. 

A  rather  firm,  dry,  sterile  dressing  should  be  applied  before  the  rubber 
tourniquet  is  removed. 

The  results  from  this  operation  are  invariably  good. 

BUNION 

Bunion  is  quite  common  but  is  usually  looked  upon  as  a  very  trivial  affair, 
although  the  discomfort  suffered  by  patients  afflicted  therewith  is  very  great. 
The  condition  is  usually  associated  with  hallux  valgus. 

Among  the  various  causes  the  wearing  of  pointed,  short  and  tight  shoes 
is  the  most  important.     Rheumatic   arthritis  may  be  a   contributing  cause. 


SURGERY  OF  THE  EXTREMITIES 


733 


734  SURGERY  OF  THE  EXTREMITIES  j 

Patients  with  a  long  great  toe  seem  more  liable  to  develop  a  condition  of 
hallux  valgus,  Avitli  the  formation  of  a  bunion,  than  those  Avith  a  short  great 
toe. 

In  cases  of  well-marked  bunion  there  is  a  true  bony  enlargement  on  the 
inner  side  of  the  head  of  the  metatarsal  bone  of  the  great  toe,  -which  becomes 
covered  with  a  bursal  layer. 

In  cases  where  the  deformity  is  only  slight,  the  wearing  of  properly  fitted 
shoes  will  often  relieve  them,  but  in  the  more  pronounced  forms  an  opera- 
tion is  the  only  method  that  att'ords  relief. 

Operation.  During  the  past  few  years  we  have  used  the  method  of  placing 
a  flap  of  the  bursa  down  over  the  end  of  the  resected  metatarsal  bone  afier  the 
method  of  C.  H.  Mayo. 

A  curved  incision  with  its  base  downwards  is  made  over  the  inner  side 
of  the  metatarso-phalangeal  joint  and  a  llap  of  skin  is  dissected  loose-leaving 
the  bursa  intact.  A  horse-shoe  shaped  incision  is  then  made  with  its  base  on 
the  phalangeal  side  of  the  joint,  loosening  the  bursa  and  folding  it  downward, 
as  shown.  The  enlarged  head  of  the  metatarsal  bone  is  now  removed  by  using 
a  pair  of  heavy  bone-cutting  forceps.  The  accompanying  illustration  shows 
the  bursal  flap  folded  downwards  and  the  metatarsal  bone  after  its  enlarged 
head  has  been  removed.  The  bursal  flap  is  now  turned  into  the  joint  area  in 
front  of  the  cut  end  of  the  bone  and  held  in  place  by  a  couple  of  catgut 
stitches  as  shown  in  the  figure.  A  small  puncture  is  made  in  the  base  of  the 
skin  flap  for  drainage  and  then  the  skin  is  closed  by  horsehair  stitches. 

In  applying  the  dressing  a  folded  piece  of  gauze  should  be  placed  between 
the  great  and  second  toes  to  overcome  the  valgus  position  of  the  great  toe. 
The  placing  of  the  bursa  in  the  joint  area  prevents  a  bony  union,  leaving  a 
movable  joint.  The  great  toe  is  shortened  and  the  foot  somewhat  narrowed 
at  its  widest  line. 

BLOOD  TRANSFUSION 

Recently  because  of  the  increased  interest  in  the  possibilities  of  trans- 
fusion, many  methods  of  transfusing  the  blood  have  been  devised,  making 
the  procedure  practical.  AVitli  the  development  of  these  various  methods, 
the  several  factors  responsible  for  the  untoward  symptoms  following  trans- 
fusion have  been  eliminated,  and  as  a  result,  transfusion  of  blood  in  the 
hands  of  an  experienced  operator  can  be  done  with  very  little  or  no  danger 
to  either  the  donor  or  recipient  of  the  blood. 

Indications.  Blood  transfusion  is  used  as  a  surgical  therapeutic  measure 
whenever  all,  or  part,  of  the  elements  of  blood  tissue  are  needed  and  cannot 
be  obtained  in  sufficient  amounts  from  the  hematopoietic  organs  of  the  in- 
dividual. These  elements  may  be  required,  (a)  to  replace  loss  of  whole  blood, 
(b)  to  increase  coagulability,  and  (c)  to  stimulate  resistance  to  infection  and 
various  other  toxic  processes. 

It  is  a  well  known  fact  that  the  administratit^n  of  normal  salt  solution  or 
the  various  modifications  of  Ringer's  solution,  either  intravenously  or  sub- 
cutaneously.  has  a  marked  beneficial  effect  in  certain  conditions  where  more 
fluid  is  needed  that  cannot  be  ingested  by  any  other  means.  By  this  form  of 
treatment,  tlien.  one  can  hope  onlv  to  give  an  increased  amount  of  body  fluid. 
On  the  other  hand,  by  transfusing  whole  blood,  one  injects  a  living  tissue 
which  has  functions  inherent  on  its  own  constituents,  and  which  thereby 
serves  an  entirely  different  purpose. 

"When  this  treatment  was  first  exploited  it  was  used,  as  is  usually  the  case, 
in  many  conditions  in  which  it  had  no  effect;  or  even  did  harm.  At  present, 
however,  we  know  that  in  many  instances  the  addition  of  fresh,  living,  whole 


SURGERY  OF  THE  EXTREMITIES  735 

blood  to  a  patient  from  another  individual  may  save  a  life,  cure  the  patho- 
logical condition  present,  or  at  least,  greatly  improve  the  patient. 

The  indications  which,  from  our  experience,  are  those  best  suited  to  this 
form  of  treatment,  will  now  be  given  in  more  detail. 

Hemorrhage.  Severe  hemorrhage  is,  of  course,  a  specific  indication  for 
blood  transfusion  and  it  is  in  these  cases  that  the  most  brilliant  results  have 
been  experienced.  In  post-operative,  post-partum,  and  gastric  ulcer  bleed- 
ing, this  method  has  been  advocated  and  used  with  success  for  a  number  of 
years.  However,  one  should  bear  in  mind  the  fact  that  nature  attempts  to 
control  the  hemorrhage  in  two  ways:  (a)  by  producing  a  fall  in  blood  pres- 
sure and  (b)  by  attempting  to  cause  a  clot  at  the  end  of  the  bleeding  vessel. 
If  additional  blood  be  supplied  in  sufficient  quantity  to  increase  the  blood 
pressure  momentarily,  a  clot  may  in  this  way  be  dislodged  and  the  hemor- 
rhage increased.  Where  it  is  possible  to  check  the  hemorrhage  by  mechanical 
means,  such  as  by  open  operation  in  gastric  ulcer  or  in  ectopic  gestation,  or 
by  packing  in  post-partum  bleeding,  blood  transfusion  both  before  and  after 
such  procedure  tides  the  patient  over  an  otherwise  frequently  fatal  period. 
It  is  in  the  severe  hemorrhages  that  large  amounts,  from  600  cc.  to  1500  cc, 
are  given.  The  transfusion  of  amounts  less  than  600  cc.  has  not,  in  our 
experience,  been  sufficient  to  control  such  cases.  We  have  also  noted  that 
amounts  greater  than  900  or  1000  cc.  do  not  produce  more  satisfactory  effects 
than  the  giving  of  600  to  800  cc,  and  repeating  one  or  more  times.  This 
amount  seems  to  be  best  suited  both  to  replace  the  lost  blood  and  to  favor 
clotting  at  the  bleeding  point. 

Secondary  anemia.  In  cases  of  persistent  oozing  of  blood  in  small  amounts 
from  any  part  of  the  body,  with  a  consequent  secondary  "drop  in  the  blood 
picture,  or  in  which  there  is  a  constant  clestruction  of  circulatory  elements 
from  an  infective  or  toxic  process,  blood  transfusion  has  been  found  of  great 
value.  Amounts  of  500  to  700  cc.  repeated  every  6  to  10  days,  do  as  much 
good  as  when  larger  amounts  are  used.  The  transfusions  should  be  repeated 
until  the  blood  picture  has  permanently  improved.  Conditions  included  in 
this  class  are,  intestinal  bleeding,  epistaxis,  pulmonary  hemorrhage,  hemor- 
rhoids, and  hematuria  from  various  causes. 

Hemophilia.  In  this  condition  there  is  a  greatly  delayed  coagulation 
time,  so  that  small  abrasions  ma}'  allow  of  severe  and  persistent  hemorrhage. 
Frequently,  the  blood  of  these-  patients  will  fail  to  clot  in  an  hour  or  more. 
Here,  blood  transfusion  may  be  employed  during  the  active  stage  of  bleeding, 
because  enough  prothrombin  will  in  this  way  be  supplied  to  produce  the 
necessary  clotting.  At  the  same  time,  the  lost  blood  is  being  replaced  by 
new  blood  elements.  For  this  reason  whole  blood  is  a  better  medium  than 
blood  serum  alone.  Even  after  the  bleeding  has  stopped,  it  is  wise  to  give 
occasional  prophylactic  transfusions  of  500  to  700  cc.  of  whole  blood  in  order 
to  supply  the  demand  for  prothrombin. 

Hemorrhagic  diseases  of  the  newborn.  In  these  conditions  the  treatment 
by  blood  transfusion  has  been  successful  in  a  large  number  of  instances,  and 
the  lives  of  many  infants  have  been  saved.  There  is,  of  course,  great  difficulty 
in  using  the  veins  of  infants,  and  for  this  reason  Helmholz  has  recently  carried 
out  a  method  which  has  been  used  in  many  cases.  He  punctures  the  anterior 
fontanelle  in  the  mid-line  and  so  enters  the  superior  longitudinal  sinus,  which 
is  a  relatively  large  vessel  in  infants. 

In  toxemia  from  any  cause,  or  where  there  is  a  condition  of  general  de- 
bility due  to  disease  or  metabolic  derangement,  blood  transfusion  has  proven 
of  marked  benefit. 

Septicemia.  We  have  seen  several  cases  of  severe  septicemia  following 
pelvic  cellulitis,  post-partum  infection  and  peritonitis  in  which  the  process 


736  SURGERY  OF  THE  EXTREMITIES 

had  gone  on  to  a  practically  hopeless  stage  and  in  which  blood  transfusion 
was  resorted  to  as  a  last  measure.  Several  of  these  cases  were  definitely 
improved  and  a  few  of  them  recovered.  It  would  seem  that  in  such  instances 
the  resistance  of  the  patient  was  just  insufficient  to  combat  the  disease.  By 
the  administration  of  whole  blood,  new  antibodies  and  fresh  red  cells  were 
furnished  which  became  the  added  stimulus  necessary  to  give  the  resisting 
process  the  upper  hand.  We  therefore  believe  septicemia,  bacteremia  and 
toxemia  to  be  favorable  indications  for  blood  transfusion. 

Banti's  disease  and  hemolytic  icterus.  These  conditions  are  essentially 
surgical  and  blood  transfusion  is  not  indicated  where  the  blood  picture  is  not 
materially  lowered.  When,  however,  the  red  cell  count  is  lower  than  2,500,000, 
or  there  are  persistent  hemorrhages,  blood  transfusion  should  be  resorted  to 
as  a  preliminary  treatment  to  splenectomy.  The  latter  procedure  offers  the 
only  hope  of  a  permanent  abatement,  but  the  previous  administration  of  new 
blood  usually  allows  of  a  better  surgical  risk.  In  fact,  blood  transfusion  has 
been  shown  by  many  different  workers  to  be  of  benefit,  at  least  temporarily, 
in  practically  every  blood  disease. 

Acute  surgical  shock.  In  cases  in  which  it  is  known  that  a  severe  opera- 
tion is  necessary,  such  as  in  carcinoma  of  the  intestine,  and  in  which  there  is 
a  marked  cachexia  and  general  weakness,  they  can  often  be  improved  in  a 
general  way  to  such  an  extent  that  the  danger  of  surgical  shock  is  markedly 
decreased.  One,  two  or  three  blood  transfusions  of  500  to  700  cc.  given  a 
week  apart  before  the  operation  will  sometimes  make  an  otherwise  hopeless 
condition  a  fairly  good  surgical  risk.  Likewise,  after  a  long,  tedious,  severe 
operation,  the  administration  of  a  pint  of  whole  blood  just  after  the  opera- 
tion is  finished  and  while  the  last  stitches  are  being  applied,  will  make  a 
r'hange  that  is  often  quite  remarkable.  A  marked  improvement  in  the  gen- 
eral condition  of  the  patient  is  evidenced  by  a  better  surface  color,  a  strength- 
ening of  the  heart  action,  and  a  drop  in  the  pulse  rate  of  30  to  50  beats  per 
minute. 

In  illuminating  gas  poisoning  there  is  a  permanent  destruction  of  the 
hemoglobin  in  the  red  cells  as  far  as  the  oxygen-carbondioxide  carrying 
capacity  is  concerned.  In  such  cases  the  transfusion  of  whole  blood,  thus 
adding  enormous  numbers  of  red  cells  and  fresh  hemoglobin,  has  in  several 
instances  saved  the  lives  of  individuals  that  would  otherwise  probably  have 
gone  on  to  a  fatal  termination. 

Pernicious  anemia.  The  employment  of  blood  transfusion  will  result  in 
marked  temporary  improvenient  in  the  vast  majority  of  cases.  Our  experi- 
ence has  been  that,  while  the  blood  picture  will  improve  immediately  in 
practically  every  case,  and  that  in  some  early  cases  a  very  prompt  and 
marked  remission  will  take  place  and  may  persist  for  a  period  of  several 
months ;  on  the  other  hand,  in  the  late  cases,  the  improvement  in  the  blood 
picture  from  the  transfusion  alone  is  very  transitor.y,  as  the  blood  will  begin 
to  decline  within  a  period  of  two  to  three  weeks,  unless  transfusion  is 
repeated. 

The  immediate  effects  of  transfusion  are  usually  quite  striking.  The  red 
blood  count  is  increased  (often  doubling  immediately  when  the  count  is  very 
low),  the  hemoglobin  percentage  rises,  and  the  number  of  platelets  is  in- 
creased. The  blast  cells  usually  become  more  numerous,  and  occasionally 
Howell's  particles  will  appear  in  the  blood,  thus  indicating  a  stimulation 
of  the  bone-marrow. 

In  patients  suffering  from  pernicious  anemia,  in  which  there  is  no  evidence 
of  involvement  of  the  central  nervous  system,  the  best  results  seem  to  be 
obtained  by  giving  a  series  of  blood  transfusions  as  a  preliminary  measure  to 
splenectomy. 

After  transfusion  the  patients  immediately,  as  a  rule,  volunteer  the  infor- 


SURGERY  OF  THE  EXTREMITIES  737 

mation  that  they  feel  stimulated  and  much  "stronger  than  they  felt  before." 
A  few  hours  later  they  become  ravenously  hungry,  while  previously  food  often 
had  to  be  forced  upon  them.  This  hunger  and  relish  of  their  food  persists 
even  after  the  red-blood  count  begins  to  fall,  which  usually  takes  place  about 
ten  days  or  two  weeks  later.  With  the  improvement  in  the  appetite  the 
mental  symptoms  grow  better,  the  insomnia  is  relieved,  and  the  glossitis 
clears  up.  There  is  no  doubt  that  the  transfusion  of  large  masses  of  whole 
blood  accomplishes  more  than  the  mere  mechanical  addition  of  so  much  blood. 
It  seems  that  it  actually  exerts  either  a  curbing  influence  on  the  hyperactive 
spleen,  or  a  stimulating  action  on  the  bone-marrow,  since  the  blood  picture 
continues  to  improve  for  several  days  after  transfusion.  This  may  be  due 
to  the  fact  that  the  blood-forming  organs  are  not  only  overworked,  but  are 
also  undernourished.  Furthermore,  multiple  blood  transfusions  supply  pro- 
tective antibodies  and  assist  the  patient  in  getting  rid  of  the  secondary 
changes  which  have  taken  place  in  the  various  organs.  During  the  period 
when  the  patient  is  being  prepared  for  operation  by  multiple  blood  trans- 
fusions, he  should  be  treated  to  eradicate  any  self-evident  infection,  such  as 
infected  teeth  or  tonsils,  pyorrhea  alveolaris,  etc. 

Preliminaries  to  trajisfusion.  The  most  important  part  of  transfusion  is 
the  selection  of  a  healthy  donor,  and  hemolytic  and  agglutination  tests  be- 
tween the  two  bloods.  In  addition  to  this,  it  is  well  to  determine  as  nearly 
as  possible  the  exact  condition  of  the  blood  before  transfusion  in  both  the 
donor  and  the  recipient.  This  examination  should  consist  of  a  red  and  white 
cell  count,  hemoglobin  percent.,  coagulation  time,  a  differential  count,  also 
noting  the  character  of  the  various  types  of  corpuscles. 

Donor.  In  selecting  a  donor,  it  is  important  in  addition  to  making  hemo- 
lytic and  agglutination  tests,  that  a  careful  history  be  obtained  from  the 
donor,  and  a  complete  physical  examination  made,  including  a  Wassermann 
test.  Donors  should  not  be  chosen  from  persons  giving  a  history  of  recent 
attacks  of  typhoid  fever,  pneumonia,  diphtheria,  tonsillitis,  malaria,  or  in- 
fluenza, or  from  persons  suffering  from  tuberculosis,  chronic  arthritis,  rheu- 
matism, or  where  there  is  a  history  of  hemophilia. 

Hemol3rtic  and  agglutination  tests.  A  hemolytic  or  agglutination  test  of 
each  blood  upon  the  other  should  always  be  made  before  transfusion,  because 
it  has  been  found  that  in  a  considerable  per  cent,  of  cases  there  is  a  tendency 
of  the  serum  of  one  blood  to  cause  a  disintegration  of  the  red  cells  of  another, 
even  when  the  latter  be  a  near  relative.  "While  the  bloods  from  members  of 
the  same  family  are  more  apt  to  be  compatible  with  each  other  than  aliens' 
blood,  still  it  is  never  safe  to  use  even  a  near  relative  as  a  donor  without 
making  an  hemolytic  test  between  the  two  bloods  to  be  mixed. 

The  technique  of  making  an  hemolytic  test  outside  the  body  is  as  follows : 
10  cc.  of  blood  is  collected  from  the  median  vein  of  the  donor  (D),  5  cc,  of 
which  is  placed  in  a  dry  centrifuge  tube  and  allowed  to  clot,  and  the  remaining 
5  cc.  mixed  thoroughly  with  10  cc.  of  one-half  per  cent,  sodium  citrate  in  nor- 
mal salt  solution.  The  latter  solution  preserves  the  red  cells  and  prevents  clot- 
ting. Both  tubes  are  now  rapidly  centrifuged.  In  one  tube  the  clotted  blood 
will  separate,  leaving  a  clear  serum  as  an  upper  layer,  1  cc.  of  this  serum  is 
then  added  to  9  cc.  of  normal  salt  solution  in  a  test  tube  and  labelled  "10  per 
cent,  solution  of  D's  serum."  The  other  centrifuge  tube  now  contains  a  com- 
pact layer  of  red  cells  in  the  bottom  and  an  upper  clear  layer  of  mixed  serum 
and  salt  solution.  This  upper  layer  is  carefully  poured  off  and  the  same 
amount  of  fresh  normal  salt  solution  so  added  with  a  pipette  as  to  mix  cells. 
The  tube  is  again  centrifuged.  This  procedure  is  repeated  ten  or  twelve 
times   in   order  to  thoroughly   wash   the   red   corpuscles   free   from   serum, 


738 


SURGERY  OF  THE  EXTREMITIES 


Finally,  1  cc.  of  the  corpuscles  is  mixed  with  9  cc.  of  normal  salt  solution 
in  a  test  tube  and  labelled  "10  per  cent,  suspension  of  D's  corpuscles." 

Ten  cc.  blood  is  collected  in  the  same  way  from  the  recipient  (R),  and  10 
per  cent,  solution  of  serum  and  10  per  cent,  suspension  of  cells  prepared  as 
above  and  placed  in  separate  test  tubes.  These  four  10  per  cent,  solutions 
and  suspensions  are  used  in  setting  up  the  test. 

In  a  clean  test  tube  1  cc.  of  D's  serum  is  mixed  with  1  cc.  of  D's  corpuscles. 
In  a  second  tube  1  cc.  of  R's  serum  is  mixed  with  1  cc.  of  R's  corpuscles.  These 
two  tubes  are  used  as  controls.  In  a  third  tube  1  cc.  of  D's  serum  is  mixed 
with  1  cc.  of  R's  corpuscles,  and  in  a  fourth  tube  1  cc.  of  R's  serum  is  mixed 
with  1  cc.  of  D's  corpuscles.  These  four  tubes  are  placed  in  the  incubator  at 
37.5°  Cent,  for  two  hours,  during  which  time  the  tubes  are  shaken  several 
times.  They  are  then  placed  in  the  ice-box  for  twelve  hours,  and  shaken  occa- 
sionally to  insure  mixing.  At  the  end  of  this  time  the  reactions  are  ready  to 
be  noted.    If  the  blood  cells  remain  as  a  layer  in  the  bottoms  of  the  tubes  and 


HH 

Bpp— 

^ 

^2 

^ 

'  ■ 

\. 

My 

l^H^^^ 

§^Y^ 

\ 

G*  ;;| 

Bp^**^ 

}i 

^W 

^^.,        -    . 

\ 

-^^f^-' 

- 

'- 

y 

^ 

i  ' 

i, 

'^■^^^mi 

^^""■^o 

.^dssm 

^1 

11 

^,.. 

Transfusion  Apparatus. 

The  Percy  transfusion  tube  and  connections.  "  A "  tube,  "  B  "  bend  for  eanula  "  C. " 
"  D  "  pressure  end.     "  T  "  glass  tube.     "  H  "  pressure  bulb.     "  G  "  mouth  piece. 

there  is  a  clear,  nearly  colorless  fluid  above ;  or  if  the  mixed  suspension  be  quite 
cloudy  and  not  transparent,  there  has  been  no  hemolysis.  If  there  are  no  red 
cells  present  as  a  layer,  or  if  the  shaken  tube  is  clear,  there  has  been  hemolysis 
of  the  red  cells.  The  two  control  tubes  should  show  no  hemolysis ;  if  they  do 
there  has  been  an  error  in  technique. 

Agglutination  test.  During  the  past  two  years  the  authors  have  been  deter- 
mining the  hemolytic  action  of  the  blood  hy  the  Moss  method,  the  technique 
of  which  has  been  modified  by  Brem.  This  method  is  based  on  the  principle 
that  before  the  serum  of  one  blood  will  cause  an  hemolysis  of  the  corpuscles 
of  another,  it  will  first,  or  simultaneously,  cause  an  agglutination  of  the  cor- 
puscles. The  reverse,  that  all  cases  that  show  agglutination  will  also  show 
hemolysis,  is  not  necessarily  true,  only  occurring  in  about  20  per  cent,  of  cases. 
Adopting  this  principle,  all  bloods  are  classified  according  to  the  agglutinative 
properties  of  their  elements  into  one  of  four  groups.  In  selecting  a  donor,  it 
is  always  advisable  to  have  one  whose  blood  belongs  to  the  same  group  as 
that  of  the  patient.  If  this  is  impossible,  the  donor's  blood  should  belong  to  a 
group  whose  corpuscles  are  not  agglutinated  by  the  serum  of  the  patient.  The 
bloods  of  group  IV  answer  this  requirement  for  all  the  other  groups,  as  its 
corpuscles  are  not  agglutinated  by  the  serum  of  any  group.     Fortunately, 


SURGERY  OF  THE  EXTREMITIES 


739 


group  IV  is  the  most  common  group,  Moss  having  found  that  43  per  cent,  of  all 
individuals  belong  to  this  group. 

Moss  found  that  all  bloods,  vi^hether  normal  or  pathological,  could  be  classi- 
fied into  four  groups  by  agglutination  tests  of  the  serums  against  the  cor- 
puscles.   He  found  the  groups  to  be  as  follows : 

Group  I.  10  per  cent. — Serum  does  not  agglutinate  corpuscles  of  any  group. 
Corpuscles  are  agglutinated  by  serum  of  II,  III  and  IV. 

Group  II.  40  per  cent. — ^Serum  agglutinates  corpuscles  of  groups  I  and  III, 
not  IV.    Corpuscles  agglutinated  by  serum  of  III  and  IV.  not  I. 

Group  III.  7  per  cent. — Serum  agglutinates  corpuscles  of  groups  I  and  II, 
not  IV.    Corpuscles  agglutinated  by  serum  of  II  and  IV,  not  I. 

Group  IV.  43  per  cent. — Serum  agglutinates  corpuscles  of  groups  I,  II  and 
III.    Corpuscles  are  not  agglutinated  by  any  serum. 

The  serum  of  one  group  will  not  agglutinate  the  corpuscles  of  blood  be- 
longing to  the  same  group. 

Moss  Chart  Showing  the  Eeaction  of  the  Various  Blood  Groups  Against  Each  Other. 

Corpuscles. 


Group 
I 

Group 
II 

Group 
III 

Group 
IV 

0 

0 

0 

0 

Group 
I 

+ 

0 

+ 

0 

Group 
II 

+■ 

+ 

0 

0 

Group 
III 

+ 

+ 

4- 

0 

Group 
IV 

In  grouping,  the  unknoM^n  blood  should  be  tested  with  a  blood  whose  group 
is  known.  This  "standard"  blood  must  belong  to  either  group  II  or  III  in 
order  to  be  of  any  value  in  grouping  other  bloods.  The  group  to  which  a  blood 
belongs  becomes  fixed  by  the  third  year  of  life,  and  remains  constant.  It  is  not 
influenced  by  age,  disease  or  transfusion  of  blood  belonging  to  another  group. 

It  will  be  seen  from  the  above  table  that  the  serums  and  corpuscles  of  the 
same  groups  do  not  in  any  way  interact.  It  will  also  be  noted  that  there  is  a 
wide,  undetermining  variety  of  reactions  possible  in  the  cases  of  groups  I  and 
IV.  The  reactions  in  the  two  remaining  groups  are  more  limited  and  definite, 
and  for  that  reason,  groups  II  or  III  only  may  be  used  as  the  standards  in  the 
Moss  test. 

The  basis  of  the  blood  examination  for  transfusion  is  the  agglutination 
reaction.  Agglutination  is  considered  as  an  early  stage  of  hemolysis,  and  is 
always  present,  hemolysis  never  occurring  without  a  primary  agglutination  of 
the  blood  cells,  while,  on  the  other  hand,  agglutination  may  occur  and  does 


740  SURGERY  OF  THE  EXTREMITIES 

occur  without  hemolysis.  It  is  from  this  agglutination  that  we  arrive  at  our 
conclusions.  The  serum  of  a  given  blood  contains  a  protective  agent  (anti- 
hemolysin)  for  its  own  corpuscles,  this  serum  having  a  tendency  to  prevent 
hemolysis.  The  serum  does  not  contain  a  corresponding  anti-agglutinin,  so 
hemolysis  may  be  prevented  without  in  any  way  hindering  the  agglutinating 
reaction.  In  the  original  method  of  Moss,  two  platinum  loopfuls  of  the 
agglutinating  serum  was  added  to  one  loopful  of  corpuscles  from  the  blood  to 
be  tested.  By  this  method  oftentimes  the  stage  of  agglutination  was  so 
transient  that  its  presence  was  not  recognized,  and  the  agglutination  went  on 
to  complete  hemolysis.  The  correct  interpretation  of  the  test  was  therefore 
impossible,  as  the  observer  failed  to  recognize  the  determining  factor — agglu- 
tination. To  remedy  this,  Brem,  besides  the  two  loopfuls  of  agglutinating 
serum  and  one  loopful  of  the  corpuscles  of  the  blood  to  be  tested,  added  one 
loopful  of  the  protecting  serum ;  that  is,  serum  of  the  same  blood  from  whence 
the  corpuscles  were  derived.  This  protective  serum,  as  we  stated  above,  con- 
tains anti-hemolysins,  but  not  agglutinins.  By  this  means  the  agglutination  is 
not  in  any  way  affected,  but  the  hemolysis  of  the  blood  cells  is  retarded  or  pre- 
vented, so  giving  a  relatively  slow,  definite,  easily  recognizable  stage  of  agglu- 
tination. The  technique,  based  upon  these  considerations,  is  as  follows:  ]0 
to  20  drops  of  blood  are  collected  in  a  small  test  tube  from  the  lobe  of  the  ear. 
This  is  allowed  to  clot,  and  then  the  tube  is  centrifuged  so  as  to  obtain  a 
clear  serum  above.  This  is  the  protective  serum  when  used  with  its  own 
corpuscles,  but  when  it  is  used  with  the  corpuscles  of  another  blood,  it  is  called 
the  agglutinating  serum.  In  another  small  test  tube  are  collected  two  drops 
of  blood  in  about  1  cc.  of  solution  composed  of  1.5  cm.  sodium  citrate,  0.9  cm. 
sodium  chloride  in  100  cc.  of  distilled  water.  This  gives  approximately  a  5  per 
cent,  suspension  of  the  corpuscles.    This  tube  requires  no  further  preparation. 

Upon  cell  slides  rimmed  with  petrolatum  to  prevent  evaporation,  are  made 
ordinary  hanging  drops. 

On  one  slide  is  put  2  loopfuls  of  standard  serum  (agglutinating  serum) 
plus  1  loopful  of  the  suspension  of  corpuscles  of  the  blood  to  be  tested,  plus 
1  loopful  of  the  protecting  serum ;  that  is,  the  serum  from  the  same  blood  as 
the  corpuscles. 

On  the  other  slide  2  loopfuls  of  the  unknown  serum,  (of  the  blood  to  be 
tested)  plus  1  loopful  of  the  suspension  of  corpuscles  from  the  standard  or 
known  blood,  plus  1  loopful  of  its  protective  serum. 

It  will  be  seen  from  the  above  table  that  one  slide  contains  the  standard  or 
known  serum,  while  the  other,  the  standard  or  known  corpuscles.  Deductions 
are  made,  using  the  standard  serum  and  corpuscles  as  a  basis  (group  II  or  III 
used  as  the  standard  groups)  after  the  agglutination  is  recognized. 

An  endeavor  should  always  be  made  to  have  the  donor  and  the  recipient 
of  the  same  groups,  so  reducing  to  a  minimum  the  possibilities  of  reactions. 
If,  in  an  emergency,  blood  must  be  given  immediately,  or  if  the  recipient  be  a 
member  of  groups  I  or  III,  the  rarer  groups,  certain  deviations  may  be  practised 
in  which  blood  of  unlike  groups  can  be  used.  Under  such  conditions,  the 
serum  of  the  recipient  must  never  agglutinate  the  corpuscles  of  the  donor, 
while  the  serum  of  the  latter  may  agglutinate  the  corpuscles  of  the  patient. 
The  serum  of  the  donor,  as  it  enters  the  blood  stream  of  the  recipient,  is 
diluted  to  such  an  extent  as  to  be  practically  inactive.  The  lack  of  agglutina- 
tion of  the  patient's  corpuscles  is  in  part  prevented  by  the  fact  that  the  re- 
cipient's corpuscles  are  protected  by  its  own  serum;  i.e.,  the  protective  serum. 

Except  in  extreme  emergency  cases,  one  is  never  justified  in  making  a  blood 
transfusion  without  first  having  made  an  hemolytic  test  between  the  two  bloods 
to  be  mixed.  Even  between  near  relatives,  such  as  sister  to  sister,  or  parent 
to  child,  etc.,  severe  fatal  hemolysis  may  occur  from  mixing  the  two  bloods. 


SURGERY  OF  THE  EXTREMITIES  741 

In  case  of  a  large  family  in  which  the  father  and  mother  are  not  in  the  same 
blood  group,  usually  some  of  the  children  will  be  in  the  same  group  as  the 
mother,  and  some  in  the  father's  groux),  and  occasionally  some  in  still  another 
group.  Thus  it  is  plain  that  a  brother  might  be  a  suitable  donor  for  one  brother 
but  not  for  another ;  also  he  might  be  a  suitable  donor  for  one  parent  and  not 
for  the  other. 

Method  of  preparation  of  the  transfusion  tube.  The  tube  must  be  dry  and 
free  from  blood.  After  use  it  is  washed  quickly  with  cold  water,  adding  lead 
shot  and  shaking,  if  necessary,  to  loosen  the  clots.  Then  wash  with  alcohol  to 
free  the  tube  of  water,  and  finally  with  ether  to  remove  the  alcohol.  \Vhen 
the  ether  evaporates,  the  tube  is  clean  and  dry.  Two  ounces  of  shredded 
grocer's  paraffin  is  placed  in  the  tube  through  the  end  "D."  It  is  then 
wrapped  in  a  towel  and  placed  in  a  steam  autoclave  for  15  minutes  at  15  pounds 
pressure.  The  tube  may  also  be  sterilized  by  placing  it  in  an  oven  or  bacterio- 
logical dry  heat  apparatus,  raising  the  temperature  to  165°  C.  for  5  minutes. 
A  higher  temperature  may  burn  the  paraffin.  At  the  end  of  this  time,  and  with 
sterile  rubber  gloves  over  the  hands,  the  tube  is  rolled  around  while  cooling  so 
that  every  part  of  the  inside  is  covered' with  melted  paraffin  and  any  excess 
allowed  to  run  out  of  the  large  end  "D."  The  paraffin  now  hardens  along  the 
inner  surface  in  a  uniform  layer.  Care  should  be  used  not  to  allow  the  canula 
to  be  plugged  with  paraffin — if  it  does,  the  tip  is  warmed  over  a  flame  and  the 
paraffin  allowed  to  run  back  into  the  tube.  Sterilizing  rubber  tubing,  glass 
"T, "  and  mouth  piece  is  done  by  placing  them  in  a  towel  and  autoclaving  in 
the  same  way  and  at  the  same  time  as  the  transfusion  tube,  or  by  boiling  them 
for  20  minutes.  The  atomizer  bulb  is  thoroughly  washed  with  alcohol  to  ster- 
ilize. When  ready  to  use,  the  connections  are  all  made,  the  rubber  clamped  at 
"Y"  and  opened  at  "X,"  and  2  ounces  of  sterile  liquid  paraffin  aspirated  into 
the  tube  through  the  canula  by  means  of  suction  at  the  mouth  piece  "G. " 

Technique  of  transfusing  the  blood.  The  arms  of  both  donor  and  recipient 
are  prepared  as  for  a  surgical  operation  and  constrictors  placed  around  both 
just  below  the  axillae.  Constriction  by  means  of  a  rubber  tube  is  not  satis- 
factory, because  the  amount  of  pressure  is  not  known,  nor  can  the  pressure  be 
varied  as  desired.  An  ordinary  blood  pressure  apparatus  pumped  up  to  60 
to  80  mm.  of  mercury,  depending  upon  the  rapidity  with  which  the  blood 
flows,  makes  an'  excellent  constrictor.  By  this  means  the  venous  circulation  is 
impeded  but  not  the  arterial,  as  shown  by  the  presence  of  a  radial  pulse.  It  is 
best  to  use  a  separate  set  of  instruments  on  different  tables  for  donor  and 
patient  in  order  not  to  transmit  infections  from  patient  to  donor.  Under  local 
anesthesia  with  one-half  per  cent,  novocain  solution  intradermally,  an  incision 
is  made  over  the  basilic  vein  just  above  its  junction  with  the  median  basilic, 
and  a  ligature  placed  about  the  vein  in  its  proximal  portion  in  the  donor,  and 
in  its  distal  portion  in  the  recipient.  Rubber-covered,  bull-dog  clamps  ai'<^ 
placed  on  that  portion  of  the  vein  away  from  the  ligature  in  each  patient  and 
a  longitudinal  incision  3  mm.  long  made  through  all  coats  of  each  vein  midway 
between  clamp  and  ligature.  Small  retention  clamps  are  placed  on  the  two 
edges  of  each  incision  in  each  vein  in  order  to  hold  them  open.  With  the 
rubber  hose  of  the  transfusion  apparatus  clamped  at  "Y"  and  open  at  "X" 
the  canula  is  placed,  pointing  distally,  in  the  vein  of  the  donor  and  the  bull- 
dog clamp  released  from  the  vein.  By  means  of  suction  at  the  mouth  piece 
"G"  venous  blood  is  drawn  into  the  tube  up  to  the  required  amount.  The 
blood  is  well  protected  from  the  sides  of  the  glass  by  the  paraffin  coat,  and 
from  the  air  by  the  liquid  paraffin  that  floats  over  and  completely  covers  the 
blood.  In  our  experience  under  these  conditions  blood  has  not  coagulated  for 
as  long  a  time  as  thirteen  minutes.  The  rubber  hose  is  now  claimped  at  "X" 
also  and  the  canula  removed  from  the  vein. 


742  SURGERY  OF  THE  EXTREMITIES 

After  removing  the  tube  from  the  donor,  the  canula  is  placed  in  the  lumen 
of  the  vein  of  the  recipient  and  the  bull-dog  clamp,  clamp  "Y,"  and  constrictor, 
are  released.  The  blood  will  now  flow  into  the  vein  of  the  recipient  toward 
the  heart,  the  velocity  of  which  flow  may  be  controlled  by  careful  contractions 
of  the  rubber  atomizer  bulb  "H. "  As  soon  as  it  is  evident  that  the  blood  is 
flowing  properh%  an  assistant  may  release  the  constrictor  from  the  donor  and 
ligate  the  vein  distal  to  the  opening  from  which  the  blood  has  been  taken. 
Horsehair  stitches  may  be  placed  in  the  skin  wound,  then  covering  the  donor's 
arm  with  a  small  sterile  dressing.  Not  more  than  four  minutes  should  be 
utilized  in  obtaining  the  blood,  nor  five  in  injecting  it.  The  length  of  time 
required  to  fill  the  tube  with  blood  varies  with  dift'erent  donors.  It  is  well  to 
have  two  tubes  ready  so  that  if  it  is  found  that  the  first  tube  fills  slowly,  tak- 
ing more  than  four  minutes '  time  to  get  the  required  amount,  the  process  may 
be  repeated  with  the  second  tube,  aspirating  only  the  remainder  of  the  required 
amount  of  blood.  Forcing  the  blood  too  rapidly  may  cause  an  acute  dilatation 
of  the  right  heart. 

After  injecting  the  blood  into  the  recipient,  the  proximal  portion  of  the 
vein  is  ligated  with  catgut  and  the  skin  sutured  as  in  the  donor.  The  entire 
procedure  may  be  carried  out  every  ten  or  twelve  days,  using  difllerent  por- 
tions of  the  same  vein,  the  corresponding  vein  in  the  other  arm  or  difit'erent 
veins  in  the  same  arm.  The  basilic  is  the  best  to  use  because  it  is  comparatively 
easy  to  find  and  the  resulting  wound  is  not  so  painful  as  when  situated  at  the 
bend  of  the  elbow. 

Quantity  of  blood.  In  adults,  600  cc.  may  be  injected  at  a  time  without 
danger.  In  patients,  however,  who  have  been  weakened  over  a  long  period  of 
time,  it  is  best  to  give  only  one-half  this  quantity  at  the  first  time.  The  pro- 
portion in  children  varies  with  age  similarly  as  the  dosage  of  drugs  varies. 

Advantages  of  this  method.  1.  Known  ciuantities  of  blood  may  be  admin 
istered. 

2.  600  cc.  can  be  given  in  from  seven  to  ten  minutes  from  the  time  the 
canula  is  inserted  into  the  donor. 

3.  Venous  blood  is  utilized  so  that  arteries,  such  as  the  radial,  are  not 
destroyed. 

4.  Transfusions  may  be  made  Avithout  contaminating  the  donor  with  th*" 
blood  of  the  recipient. 

5.  No  air  comes  in  contact  with  the  blood  thus  lessening  the  liability  of 
clotting. 

6.  There  is  direct  communication  between  vein  and  chamber  by  a  simple 
paraffin-lined  glass  tube.  There  are  no  metal,  rubber  nor  other  connections 
whose  edges  cause  resistance  to  the  flow. 

7.  All  of  the  apparatus  is  simple  and  can  be  made  hy  any  good  glass- 
blower. 

Reactions  following  transfusion.  The  majority  of  our  patients  have  not 
experienced  any  noticeable  reaction  whatsoever.  In  about  5  per  cent,  of  the 
cases  a  slight  chill  has  occurred,  followed  by  temperature,  and  in  an  additional 
5  per  cent,  a  mild  temperature  developed  the  same  evening  or  day  following 
the  transfusion.  This  applies  to  transfusions  in  which  the  patient  and  donor 
were  in  the  same  blood  group,  as  classified  by  Moss.  Whenever  Ave  deviated 
from  this  and  used  a  donor  from  a  different  blood  group  than  that  of  the 
recipient,  as  was  occasionally  necessary,  the  transfusion  was  usually  followed 
by  a  marked  chill  and  temperature.  A  donor  from  a  different  group  than  that 
of  the  recipient  was  never  used  except  Avhen  the  patient  Avas  in  one  of  the 
rarer  groups,  and  it  Avas  difficult  to  find  a  donor  belonging  to  the  same  group. 
In  these  instances,  a  donor  Avas  chosen  from  group  IV,  a  group  AA'hose  cor- 
puscles Avould  not  be  agglutinated  by  the  serum  of  the  recipient. 


SURGERY  OF  THE  EXTREMITIES  743 

Factors  of  safety.  The  chief  points  to  be  borne  in  mind  in  blood  trans- 
fusion are :  the  avoidance  of  hemolysis,  air  embolism,  clot  embolism,  and  acute 
dilatation  of  the  heart. 

The  greatest  risk  from  the  operation  is  that  from  hemolysis.  This  danger 
can  be  avoided  in  the  vast  majority  of  cases  if  careful  hemolytic  and  agglutina- 
tion tests  are  always  made  preliminary  to  transfusion.  While  laboratory 
methods  have  their  limitations  and  are  not  infallible,  still,  if  the  tests  are 
always  carefully  made,  the  danger  from  hemolysis  is  slight. 

The  danger  from  air  embolus  and  clot  embolus  can  always  be  avoided  if 
proper  care  is  exercised  in  carrying  out  the  technique  of  the  operation. 

The  danger  of  acute  dilatation  of  the  heart  is  probably  not  as  great  as  is 
generally  supposed.  So  far,  the  authors  have  not  encountered  a  case  in  which 
there  was  any  evidence  of  the  heart  having  been  embarrassed  by  the  trans- 
fusion. It  is  well,  however,  not  to  inject  the  blood  too  rapidly  in  very  weak 
and  anemic  patients,  especially  if  it  be  the  first  transfusion. 

Summary.  1.  Transfusion  of  blood  is  the  most  efficient  means  at  our 
command  for  treating  hemorrhage  and  the  majority  of  hemorrhagic  diseases, 
as  well  as  many  of  the  wasting  diseases. 

2.  The  proper  selection  of  donors  by  adequate  preliminary  tests  for  com- 
patibility is  essential. 

3.  Amounts  of  from  500  to  800  cc.  of  whole  blood,  repeated  at  intervals  of 
seven  to  fifteen  days,  are  most  desirable. 

4.  A  simple,  rapid  method  of  transfusing  should  be  used.  This  should 
preferably  be  one  in  which  plain,  whole  blood  is  administered  without  mixing 
with  any  foreign  substance ;  furthermore,  the  blood  should  not  be  unduly  ex- 
posed to  the  air,  and  the  interval  that  it  is  out  of  the  circulation  should  be 
reduced  to  a  minimum.  An  indirect,  closed  method  by  means  of  a  prepared 
container  seems  to  best  answer  the  requirements. 


PART  XI 

MODERN  MILITARY  SURGERY 


INTRODUCTION* 


Although  military  surgery  is  in  many  respects  different  from  civil  practice, 
there  has  been  noted  a  marked  tendency  of  some  of  the  workers  to  overlook 
the  general  principles  of  surgerj-.  The  principles  that  underlie  ordinary  and 
civil  surgery  are  identical,  in  the  main,  with  those  that  govern  the  injuries 
due  to  the  use  of  modern  firearms,  and  a  surgeon  who  is  to  serve  on  the 
battle-field  needs  just  as  sound  a  preparation  under  the  guidance  of  a  master 
as  if  he  were  to  remain  at  home.  In  fact,  the  exigencies  of  war  are  such  that 
the  injured  must  have  the  best  possible  care  in  order  that  they  may  return 
to  the  front,  for  the  most  important  factor  of  all  is  the  winning  of  the  war. 
It  is  only  through  competent,  efficient  and  well-trained  men  that  the  surgical 
work  of  an  army  can  be  brought  to  the  standard  demanded  by  the  conditions 
of  war. 

When  the  present  war  began  there  were  but  immature  preparations  made 
for  the  handling  of  the  wounded,  resulting  in  a  high  rate  of  mortality  and  of 
disabilities.  These  facts  were  noted  at  once,  however,  and  the  surgical  corps 
of  all  armies  immediately  took  steps  to  improve  their  work  and  the  conditions 
under  which  they  labored,  with  the  result  that  the  surgical  departments  of 
all  the  armies  have  become  highly  efficient. 

It  is  our  plan  in  this  section  to  describe  only  those  methods  of  treating  the 
wounded  which  we  have  tried  and  found  useful,  or  which,  in  our  judgment 
and  viewed  from  our  former  experiences,  are  methods  that  seem  logical  and 
reasonable.  Naturally,  there  has  been  an  enormous  amount  of  surgical  liter- 
ature prompted  by  the  conditions  in  Europe,  and  so  a  summary  only  of  the 
most  important  and  lasting  experiences  will  be  given. 

The  main  surgical  peculiarities  of  the  present  war  are  undoubtedly  du-? 
to  the  nature  of  the  weapons  and  to  the  conditions  under  which  the  wounds 
are  received  and  in  which  the  injured  man  must  exist  for  some  time  after  the 
injury.  It  is,  then,  more  a  question  of  the  environment  than  of  the  nature  of 
the  wounds. 

War  surgery  is  the  surgery  of  gunshot  wounds.  Such  wounds  are  pro- 
duced by  bombs,  hand  grenades  and  indirect  missiles,  as  well  as  injuries  from 
projecting  large  and  small  guns.  The  great  difference  between  civil  and 
military  surgery  is  due  to  the  immense  difference  in  the  conditions  under 
which  the  work  is  done.  The  civil  surgeon  operates  under  aseptic  conditions 
that  are  practically  ideal,  while  the  military  surgeon  only  infrequently  sees 
a  case  that  is  not  infected.  The  wounded  man  is  often  exhausted  by  the 
fatigue  and  privations  of  campaigning  when  he  falls  on  a  soil  that  is  infected 


*  The  authors  stand  indebted  to  Fauntleroy's  Seport  on  the  Medico-Militarii  Aspects  of 
the  Eiiropean  War,  for  many  of  the  illustrations  reproduced  in  this  section  in  modified  form. 

745 


.746 


MODERN  MILITARY  SURGERY 


with  all  of  the  virulent  pyogenic  organisms  found  in  fecal  matter  and  on 
which  he  is  apt  to  lie  for  days  before  surgical  aid  can  reach  him.  He  is  next 
subjected  to  the  trying  influence  of  long  and  often  improvised  transport, 
during  which  proper  food,  good  nursing,  rest,  and  favorable  environment  are 
frequently  absent.  Hospitals  must  be  improvised  at  the  beginning  of  the  cam- 
paign and  these  are  often  overcrowded  from  the  sudden  influx  of  wounded 
following  a  battle.  This  overcrowTling  usually  brings  a  scarcity  of  food  and 
of  surgical  supplies.  To  add  to  the  difficulties  at  hand,  the  wounds,  which 
are  practically  all  infected,  are  of  manifold  varieties,  occurring  in  all  parts 
of  the  body  and  involving  every  tissue.  ^Military  surgeons  in  the  United 
States,  who  treated  gunshot  wounds  on  hot,  dry,  sterile  plains,  with  plenty  of 
fresh  air  and  sunshine,  were  seldom  troubled  with  the  complications  arising 
from  the  varied  infections  now  shown  on  European  battle-fields. 


Illitstrating  Marked  Mutilating  Effect  of  Bomb  Wound  of  the  Face. 


The  present  method  of  entrenched  warfare  is  far  different  from  that  of 
any  previous  war.  Men  remain  for  months  in  deep  holes,  often  contaminated 
by  excreta.  In  these  underground  holes  and  tunnels  they  are  striken  by 
shells,  shrapnel  bombs  or  bullets  from  above,  or  blasted  from  their  positions 
by  mines  planted  beneath  the  trenches.  This  type  of  w^arfare  is  the  cause  of 
a  greatly  increased  primary  mortality  and  of  the  terribly  mutilated  flesh  and 
bone  wounds  now  so  frequently  seen. 

Another  difference  in  the  present  effects  of  war  is  in  the  type  of  missiles 
used.  The  high  velocity,  pointed,  but  unbalanced  bullet,  the  shrapnel  with 
a  variety  of  sizes  and  speed  of  its  irregular  missiles,  and  the  bombs  with  their 
destructive  effects,  all  produce  w^ounds  which  have  seldom  been  seen  before 
the  present  war  began. 

While  there  has  been  an  enormous  amount  of  infection  of  wounds  pro- 
duced, it  is  a  most  significant  and  gratifying  fact  that  no  great  epidemics  of 
the  plague,  typhoid  fever,  typhus  fever,  tetanus,  or  small-pox  have  been  extant. 
This  is  a  result  of  the  most  efficient  work  of  the  sanitary  corps  of  each  army 


MODERN  MILITARY  SURGERY 


747 


in  the  field.  While  it  is  admitted  that  a  few  smaller  epidemics  of  some  of  the 
infectious  diseases,  such  as  small-pox  and  measles,  have  broken  out  occa- 
sionally, these  have  been  quickly  suppressed,  so  that  no  army  has  suffered 
great  loss  since  the  deplorable  typhus  epidemic  of  Serbia  in  the  first  few 
months  of  the  war.  The  sanitary  units  of  each  army  are  at  present  a  very 
important,  and  at  the  same  time  efficient,  part  of  the  service,  for  army  officials 
realize  that  such  service  has  kept  a  greater  proportion  of  men  on  the  lines 
than  in  any  other  war. 

Great  strides  have  been  made  in  methods  of  transporting  the  wounded 
from  the  battle-field  to  the  dressing  station  or  hospital.  xVmbulance  companies 
are  organized  by  the  governments  under  which  they  are  working  or,  as  is 
usually  the  case,  by  the  Red  Cross  Association  or  by  private  interests. 

Base  hospitals  are  now  being  established  nearer  the  front  than  formerly, 
and  casualty  clearing  stations   are  gradually  being  discontinued.     For  this 


Showing  Different  Degrees  of  Trenchfoot. 


reason  railroad  transportation  of  the  wounded  has  assumed  much  greater  pro- 
portions. While  it  is  true  that  many  patients  could  have  their  wounds  properly 
dressed,  or  operations  performed,  to  better  advantage  if  done  within  a  very 
few  hours,  still  the  opinion  is  that  hospitals  of  thorough  enough  equipment 
cannot  be  established  close  to  the  firing  line.  Patients  can  usually  be  admitted 
to  base  hospitals  at  the  present  time  in  from  a  few  hours  to  two  days  after 
receiving  their  injuries.  At  such  hospitals,  then,  primary  major  operations 
may  be  performed  with  a  much  more  favorable  environment.  It  is  also  the 
practice  in  England,  France  and  Germany  to  establish  specialist  centers  in 
each  military  zone,  so  that  now  there  are  hospitals  for  the  head  and  neck,  for 
the  eyes,  for  the  feet,  for  fractures,  for  nerve  injuries,  etc.  Specialists  are 
located  at  these  various  hospitals  and  the  patients  are  evacuated  to  them  from 
the  base  hospitals  at  intervals.  The  majority  of  these  hospitals  are  located 
in  the  interior;  those  of  the  English  army,  in  England,  those  of  France,  in 
the  larger  cities,  like  Paris  and  Lyons,  and  those  of  Germany  an  I  Austria, 
in  the  larger  cities,  such  as  Berlin  and  Vienna. 


748  MODERN  MILITARY  SURGERY 

The  lessons  learned  from  the  unprecedented  use  of  heavy  armament,  of 
high  explosive  charges  of  terrific  detonating  power,  of  enormous  numbers 
of  machine  guns  and  of  predominant  trench  warfare  during  the  European 
war  of  1914-1917,  are  certain  to  dominate  the  methods  of  warfare  for  some 
time  to  come. 

As  a  direct  consequence  of  these  modern  factors,  the  nature  and  relative 
frequency  of  military  wounds  has  been  materially  altered.  The  problems  of 
trench  fighting  have  become  those  of  siege,  rather  than  of  mobile  warfare, 
and  the  necessity  for  blasting  men  out  of  reinforced  earthen  entrenchments  by 
high  explosive  shells  has  led  to  the  natural  result  that  wounds  from  artillery 
projectiles  have  become  more  than  twice  as  frequent  as  bullet  wounds; 
whereas  in  the  various  types  of  mobile  warfare,  artillery  wounds  seldom  ex- 
ceed from  10  to  25  per  cent,  of  all  wounds.  Trench  warfare  has  also  been 
responsible  for  a  sharp  increase  in  the  proportion  of  killed  to  wounded,  this 
rising  from  about  1  to  5,  as  reported  by  the  British  in  the  Boer  war,  to  about 
1  to  3  for  all  classes  of  military  activity,  and  about  1  to  2  in  essential  trencli 
fighting,  the  greater  frequency  of  projectile  injuries  to  the  head,  due  to  its 
relatively  greater  exposure,  and  the  excessive  mortality  of  the  wounds,  being 
largely  instrumental  in  this  increase. 

PROJECTILES 

The  general  care  of  battle  wounds  presupposes  a  knowledge  of  the  con- 
ditions of  employment  of  shrapnel,  shells  and  bullets,  of  the  mechanism  of  their 
action,  and  of  their  characteristic  effects  upon  living  tissues. 

Shrapnel,  which  are  responsible  for  about  three-fourths  of  all  artillery 
wounds  in  mobile  warfare,  consist  of  cylindro-conoidal  casing  of  cupro-steel, 
weighing  from  15  to  20  pounds,  containing  from  300  to  500  round  lead  bullets 
usually  hardened  with  antimony,  from  1  to  1.5  cm.  in  diameter  and  weighing 
from  10  to  16  grams  each.  These  are  imbedded  in  a  smoke-producing  matrix, 
usually  a  variety  of  sulphur,  which  indicates  the  point  of  explosion  to  the 
artillery  observer.  The  base  of  the  cylinder  contains  a  bursting  charge  of 
some  high  explosive,  usually  of  terrific  detonating  power,  which  is  timed  by 
a  fuse  in  the  detachable  head,  to  explode  at  any  given  point  in  the  projectile's 
flight,  or  on  impact.  The  characteristic  feature  of  shrapnel  which  determines 
the  main  use  and  makes  it  most  effective  against  bodies  of  troops  in  the  open, 
forward  and  downwards  in  a  cone-shaped  stream,  whose  velocity  depends 
is  the  forward-reaching  of  the  charge  after  bursting,  the  bullets  being  propelled 
upon  the  velocity  of  the  shell  rather  than  upon  the  power  of  the  bursting 
charge. 

Each  shrapnel  bursts  into  from  2  to  3000  fragments,  varying  in  size  from 
large  irregular  pieces  of  casing  possessing  all  the  terrible  lacerating  effect 
of  solid  shot,  to  jagged  lumps  of  metal  and  fine  sharp  slivers.  More  than  70 
per  cent,  of  the  ammunition  used  by  field  guns  in  modern  battle  is  in  the  form 
of  shrapnel  and  anti-aircraft  guns  are  exclusively  of  this  type. 

The  effect  of  shrapnel  bullets  is  like  that  of  the  old  rifle  bullet,  in  that  the 
power  of  penetration  is  comparatively  slight.  They  cause  local  depressed 
fracture  of  the  skull  without  laceration  of  the  dura  much  more  often  than  they 
perforate  the  dura  and  lodge  in  the  brain.  The  characteristic  tendency  of  a 
shrapnel  ball  is  to  break  one  bone  and  to  lodge  immediately.  At  first  it  was 
reported  that  only  about  40  per  cent,  of  all  shrapnel  wounds  were  infected, 
but  now  it  is  known  that  practically  all  are  primarily  infected.  It  is  certain 
that  infection  is  the  most  serious  element  of  these  wounds  and  often  fatal. 
The  literal  covering  of  entrenched  soldiers  with  mud,  largely  manurial  in 
origin,  is  mainly  responsible  for  this  excessive  infection  in  trench  warfare. 


MODERN  MILITARY  SURGERY 


749 


Shells,  among  wliicli  are  inclnded  bombs,  grenades  of  all  kinds,  and,  from 
their  similarity  in  effect,  mines,  range  from  sizes  scarcely  larger  than  shrapnel 
to  great  cylindro-cones  as  tall  as  a  man  and  Treighing  over  a  ton.  The  cavities 
of  these  iron  or  steel  casings  enclose  a  violent  explosive  charge  which,  in  the 
case  of  bombs  and  hand  grenades,  is  often  partly  replaced  by  irregular  metal 
fragments  of  all  kinds,  as  well  as  by  corrosive  fluids  and  irritant  and  poisonous 
gases. 

A  characteristic  feature  of  the  wounds  is  the  formation  of  numerous  "'pock- 
ets," owing  to  the  separation  of  muscle  layers  along  the  fascial  planes,  a 
matter  of  great  importance  if  infection  is  allowed  to  gain  a  foothold.     Sur- 


% 


Types  of  Shrapxel  ix  Moderx  U&e. 


gical  experience  has  shown  that  the  larger  and  more  irregular  the  missile,  the 
greater  the  probability  of  infection  from  the  larger  amount  of  tissue  torn 
and  exposed;  and  as  shell  fragments  are  always  rough  and  jagged,  these 
wounds  are  nearly  always  found  infected.  Streptococci  and  staphlococci 
are  invariably  present,  with  the  fecal  organisms  of  tetanus  and  gas-gangrene 
frequently  super-added. 

Bullets  in  modern  warfare  are  all  pointed  and  they  tend  to  flow  oi|t  of 
shape  and  to  fragment  upon  meeting  slight  obstructions,  because  of  the 
diff'erence  in  the  density  of  the  core  and  the  thin  outer  jacket.  Because  of  its 
deliberately  imperfect  balance,  it  has  a  wabbly,  gyrating  motion  during  the 
first  800  yards  of  its  flight,  as  well  as  when  nearly  spent.  This  imbalance 
often  causes  the  bullet  to  somersault  or  turn  on  its  axis  when  it  meets  the  least 


750 


MODERN  MILITARY  SURGERY 


resistance,  and  if  this  resistance  be  that  of  the  tissues,  the  bullet  produces  a 
deep,  irregular  wound  often  with  large  cavities  in  the  soft  tissues,  as  is  typical 
of  the  dum-dum  bullet.  In  this  war,  where  the  fight  often  takes  place  amongst 
houses,  there  are  many  opportunities  for  the  bullet  to  be  deformed  and  de- 
flected. Again,  the  velocity  and  stability  of  a  bullet  is  largely  affected  by 
passing  through  sand  bags  or  a  parapet,  which,  as  a  matter  of  fact,  has  to  be 
about  four  feet  thick  in  order  to  be  bullet-proof. 

There  is  plenty  of  evidence  that,  whether  from  adherent  instability  or 
from  hitting  some  object,  the  bullet  does  spin,  and  in  several  cases  a  bruised 
impress  has  been  seen  on  the  skin  which  could  only  have  been  made  by  a 
sidelong  impact  of  the  bullet.  Again,  in  those  cases  where  two  legs  have 
been  wounded  by  the  same  bullet,  the  first  leg  has  been  perforated  by  a  small 
track,  and  the  opposite  leg  has  suffered  a  large  gaping  wound,  the  obvious 
explanation  being  that  the  bullet  in  passing  through  the  first  leg  was  made 


Actual    size   of   rreuch   car- 
tridge "D." 


Actual  size   of  German  car- 
tridge "S." 

Pkesent-Day  Cartridges. 


Actual    size   of    English 
cartridge. 


to  spin,  and  so  caused  a  more  extensive  wound  on  the  opposite  member.  A 
good  deal  has  been  said  about  the  explosive  effect  of  the  modern  pointed 
bullet,  but  the  evidence  shows  that  it  is  this  gyrating  and  spinning  action 
which  causes  the  large,  irregular,  destructive  wounds. 

Captain  Bashford  (Brit.-Jour.  of  Surg.,  January  1917,  p.  452)  has  made  an 
extensive  gross  and  microscopical  study  of  the  tissues  involved  in  gunshot 
wounds,  and  his  conclusions  follow:  "Although  the  obvious  local  effects  of 
gunshot  wounds  may  sometimes  be  surprisingly  extensive  in  their  ragged  rami- 
fications, the  foregoing  observations  show  that  remote  and  other  far-reaching 
effects  are  by  no  means  universal.  Indeed,  during  eight  months  of  close 
attention  to  so  imDortant  a  subject,  I  have  failed  to  find  any  evidence  that  they 


:\IODERN  MILITAEY  SURGERY 


751 


occur  at  all  in  the  organs  or  tissues  examined.  If  vibration  be  set  up  by  the 
projectile  in  the  tissues  of  the  body,  it  does  not  result  in  capillary  hemorrhage, 
except  in  situations  where  they  would  be  expected — for  example,  under  the 
capsule  of  the  kidney ;  and  remarkable  disintegration  of  cells,  or  even  injury 
of  any  sort  at  a  considerable  distance  from  the  obvious  site  of  the  injury — have 
not  been  met  with.  The  heavy  infection  of  tissues  by  bacteria,  effected  by  the 
passage  of  projectiles,  would  of  itself  serve  to  shake  any  belief  in  vibration 
being  an  efficient  cause  of  cell-death,  apart  from  the  influence  of  direct  violence. 
The  facts  set  out  above  are  all  in  favor  of  conservative  surgery  in  gunshot 
injuries.  By  a  too  extended  removal  of  tissues  adjacent  to  the  injury,  the 
gap  which  has  to  be  filled  may  often  be  made  needlessly  great,  and  the  duration 
of  the  period  of  recovery  needlessly  increased,  leaving  out  of  all  consideration 


■^fSt** 


Actual  Size  of  Shrapnel  Buxlets  and  Pieces  of  Shell. 

Shrapnel  wounds  are  accompanied  by  considerable  destruction  of  the  deep  tissues  in 
consequence  of  the  "mushroom"  effect  of  the  soft,  unjaeketed  lead  missile,  particularly  when 
hard  bone  is  encountered.     These  wounds  are  always  infected,  often  very  intensely. 


other  possible  contingencies."  He  shows  this  point  by  many  illustrations, 
some  of  which  are  reproduced  here. 

Bombs  and  grenades.  In  the  earlj^  part  of  the  war  bombs  were  often  ex- 
temporized, and  consisted  of  tin  boxes  filled  with  an  explosive,  scrap  iron, 
cobbler's  nails  and  screws,  etc.  Now  they  are  made  of  iron,  the  surface  of 
which  is  marked  with  grooves,  so  that  on  explosion  they  break  up  into  quadri- 
lateral fragments.  Sometimes  the  force  of  the  explosive  will  cause  the  bomb 
to  burst  into  smaller  fragments  often  no  larger  than  a  matchhead.  Although 
small,  these  fragments  have,  apparently  from  their  high  velocity,  a  very  great 
penetrating  power  in  the  immediate  neighborhood  of  the  explosion,  though 
this  is  rapidly  lost  as  the  distance  increases. 

Trench  mortars.  Bombs  from  these  are  of  various  shapes,  but  consist 
essentially  of  a  very  large,  high-explosive  charge  with  a  comparatively  thin 
containing  envelope ;  they  therefore  very  often  burst  into  large  ragged  frag- 


752  MODERN  MILITARY  SURGERY 

/nents,  as  well  as  minute  ones,  and  are  generally  timed  to  burst  either  on  the 
surface  or  in  the  ground. 

Bayonet  wounds,  although  seldom  met  with,  make  up  practically  all  the 
incised  wounds  seen  in  modern  warfare.  A  direct  thrust  into  any  part  of 
the  body  that  allows  of  the  passage  of  a  bayonet  is  practically  always  fatal. 
Since  bayonets  are  frequently  used  as  accessory  trench  and  camp  tools,  their 
wounds  are  nearly  always  infected.  AVallace  describes  two  cases :  In  the 
first  the  bayonet  penetrated  the  man's  back  and  emerged  through  his  um- 
bilicus ;  no  viscus  was  injured,  but  the  man  succumbed  to  hemorrhage.  The 
second  was  the  case  of  a  man  who  was  late  in  answering  a  challenge  and  was 
bayoneted  by  the  sentry ;  the  bayonet  entered  the  left  hypochondrium,  wounded 
the  greater  curvature  of  the  stomach  and  entered  the  back  wall  of  the  ab- 
domen. Though  promptly  operated  upon,  he  died,  not  of  his  stomach  wound, 
but  of  retroperitoneal  sepsis. 

Cuthbert  Wallace  {British  Jour,  of  Surg.,  IV,  1916,  684)  gives  interesting 
statistics  which  are  as  follows : 

"Relative  niimhcr  of  different  projectiles,  and  the  proportion  retained.''^ 
The  following  table  has  been  drawn  up  Avith  the  intention  of  giving  some  idea 
of  the  relative  frequency  of  the  different  projectiles  met  with  in  abdominal 
wounds ;  it  also  shows  the  relative  number  retained  in  the  body.  This  table 
must  be  taken  as  only  approximately  correct  for  several  reasons.  In  the  first 
place,  it  is  often  impossible  for  a  man  to  tell  what  hit  him.  In  the  second 
place,  one  cannot  always  be  sure  from  a  study  of  the  entrance  and  exit  wounds 
what  was  the  nature  of  the  projectile ;  and  again,  many  do  not  difi'erentiate 
between  high-explosive  shell  and  shrapnel.  As  a  matter  of  fact,  there  is  very 
little  difl:'erence  in  the  nature  of  the  fragments  in  high-explosive  shells,  bombs, 
rifle  grenades,  or  trench  mortars,  if  one  excludes  the  larger  fragments,  with 
which  we  are  very  little  concerned. 

Shell  Bomb  or 

Bullet         Fragment  Shrapnel  Grenade 

Passed  through  and  out 203                   30  15                     6 

Retained    131                 254  67                 128 


Total 334  284  82  134 

Bullets.  Bullets  and  high-explosive  shells  furnish  a  large  proportion  of 
wounds.  More  bullets  pass  through  the  body  than  any  other  projectile ;  the 
reason  for  this  is  obvious.  The  causes  for  retention  are  not  so  obvious,  and  I 
have  known  bullets,  fired  at  a  comparatively  short  distance,  to  remain  within 
the  body.  In  other  cases  the  bullet  may  have  passed  through  the  earth  and 
so  have  had  its  velocity  diminished.  Ricochets  account  for  a  certain  number 
remaining. 

Shells.  These  show  a  high  proportion  of  retention,  which  is  obviously  due 
to  the  shape  of  the  fragments. 

Bombs  and  grenades.  The  retained  fragments  are  strikingly  in  excess  of 
those  passed  out. 

The  large  proportion  of  retained  fragments  at  once  suggests  the  possibility 
of  armour ;  and  no  doubt  armour  could  be  devised  which  would  keep  out  many 
fragments.  It  really  is  more  or  less  a  question  of  what  a  soldier  is  able  to  carry. 
One  cannot  help  being  struck  with  the  resistive  power  of  an  ordinary  book,  as 
one  has  often  seen  projectiles  arrested  by  such  articles  when  carried  by  the 
soldier.    The  great  saving  of  life  effected  by  the  steel  helmet  make  one  hope 


MODERN  MILITAEY  SURGERY  753 

that  something  may  be  produced  equally  efficacious  in  protecting  the  body. 
Although  we  could  not  expect  such  shields  to  be  supportable  and  at  the  same 
time  bullet  proof,  yet  the  number  of  bullets  is  greatly  outnumbered  by  shell 
and  bomb  fragments,  which  possess  far  less  penetrative  power. 

Shell  Bomb  or 

Bullet         Fragment  Shrapnel  Grenade 

To  base    91                 105  15                   60 

Died    106                154  40                  58 

Total 197  259  55  118 

Relative  mortality  of  the  different  projectiles.  The  above  table  shows  that 
bullets  are  but  little  less  dangerous  than  shells,  and  that  bombs  and  grenades 
are  the  least  noxious. 

THE  GENERAL  CARE  OF  THE  SICK  AND  WOUNDED 

Aside  from  the  control  of  severe  hemorrhage  and  the  fixation  of  fractures, 
the  most  important  primary  treatment  is  that  of  the  general  condition,  for 
the  psychic  and  physical  shock  is  often  of  more  importance  in  the  recovery 
of  the  patient  than  is  the  treatment  of  his  wounds  later  on.  Bowlby,  quoted 
bv  Mills,  {British  Jour,  of  Surg.,  Dec.  25,  1915)  illustrates  this  vividly:  "When 
the  intense  excitement  of  fighting  for  life  and  killing  other  men  in  the  midst 
of  the  crash  of  shells  and  the  clatter  of  rifles  and  machine  guns  has  passed, 
then  there  comes  the  reaction  and  the  exhaustion  of  a  tired-out  man  and  an 
over-wrought  nervous  system.  Those  who  only  see  the  men  in  the  base  hos- 
pitals have  little  idea  of  the  silence  of  a  crowded  room  in  a  clearing  station 
when  heavy  fighting  has  been  in  progress  for  a  day  or  two.  There  are  hun- 
dreds of  men  whose  best  chance  in  life  is  to  be  kept  warm  and  left  absolutely 
quiet  and  persuaded  to  take  hot  soup  or  cocoa  before  again  going  to  sleep. 
It  is  at  first  surprising  to  find  how  many  quiet,  pulseless  men  will  pull  around 
if  given  time  and  kept  thoroughly  warm.  Often  they  are  so  nearly  dead  that 
it  may  be  several  hours  before  an  attempt  can  be  made  to  dress  their  wounds, 
and  even  with  every  care  there  are  not  a  few  who  die." 

Numerous  lives  have  been  saved  by  the  free  subcutaneous  and  intravenous 
injection  of  normal  saline,  by  proctoclysis  of  hot  saline  solution,  coffee  or 
brandy,  and  by  hypodermics  of  an  opiate  to  relieve  pain.  Efficient  voluntary 
care  of  the  stricken  soldiers  by  nurses  and  town  folks  has  done  much  to  alle- 
viate their  sufferings. 

The  patient  should  be  given  every  consideration  that  is  possible  under  the 
circumstances.  He  should  be  allowed  to  rest  and  not  unnecessarily  moved 
while  in  a  condition  of  shock  or  pain.  He  should  have  plenty  of  fresh  air  and 
a  good  light  room.  General  or  regional  anesthesia  should  be  administered  in 
procedures  necessitating  a  great  amount  of  pain.  Morphine  in  doses  of  one- 
fourth  to  one-half  grain  hypodermically  is  usually  allowed  the  men  with  pain 
during  transportation. 

The  evacuation  and  care  of  the  sick  and  wounded  has  always  constituted  a 
problem  of  the  greatest  importance  in  every  campaisrn  of  history.  Progress 
in  this  direction  has  not  by  any  means  kept  pace  with  the  advances  made  in 
perfecting  the  means  for  destroying  human  life  and  -property.  The  history  of 
every  war  has  shown  that  the  constant  workinsr  formula,  so  often  quoted, 
"ammunition  first,  food  second,  and  wounded  third."  has  not  changed,  nor 
has  it  received  the  consideration,  in  regard  to  alleviating  the  condition  of  the 
last  factor  in  this  formula,  that  its  importance  warrants. 


754 


MODERN  MILITARY  SURGERY 


y 


r 

mwMss^j^ 

^ 

A 

i 

MODERN  MILITARY  SURGERY 


755 


Hospital  organization  and  capacity  in  the  battle-field  have  undergone  many 
variations  during  previous  conflicts  and  especially  the  present  great  war.  The 
experience  of  George  W.  Crile,  {Jour.  Am.  Med.  Ass'n,  LXIX,  4,  page  292) 
who  has  been  in  charge  of  an  American  base  hospital  in  France,  is  summarized 
as  follows : 


N^'CORP^ 


'l5t  DIVI5lON'^ 


^     r 


'2rdDIVI3rON"^ 


+      + 

\         / 


III  III  lll  ill 
t  t    BATTERIES    +  + 


\ % 


A 


^ 
©-.. 


i  Hospital- ^ECTTorf 
:  AMD 


.J   %/i 


ffijpi* 


SEVACLTATroN 
Hospital  *— 


•  PETUGE-roP-WOUrtDED 
+  FIRiT-AID  •  jTATlOr^J 
19  C0PRS-tvo-DIV-(3?0UP^ 
or  •  L1TTER«BEARER3 
®  AMBULANCE  ■ 
lil^do—  IMMOBILIZED. 

E  Hospital -^ECTion 

f*.SX\TIoN%-5LIGHTLY 

•^^oUrSDED* 
^4^  AUToMoBILE-AMBUL"? 
CS^^j.  .SUEClCAL«nELD«Ho2Pt 


Aemt  Corps  Stjegical  Unit. 

The  first-aid  station  is  in  some  sheltered  spot,  or  the  cellar  of  a  house,  usually  from  500 
to  1,000  yards  behind  the  reserves,  and  is  provided  with  water,  large  and  small  dressings  and 
other  facilities  for  the  rapid  treatment  of  wounds.  Antitetanic  serum  is  injected  and  the 
wounded  then  tagged  and  grouped  for  transfer  to  the  rear.  The  diagram  shows  the  disposi- 
tion of  the  sanitary  units  and  formations  for  one  army  corps.  It  represents  the  actual  organi- 
zation of  the  surgical  work  at  the  front,  yet  each  unit  or  formation  is  to  take  advantage  of 
any  local  protection,  such  as  behind  a  hill.  Therefore  the  distances  to  each  group  or  station 
may  vary,  and, the  first-aid  stations  may  be  at  convenient  points  at  cross  roads  or  in  a  village. 


"1.  On  account  of  the  remarkably  wide  and  sudden  fluctuations  in  the 
number  of  casualties,  hospitals  should  be  so  constructed  and  their  personnel 
so  organized  as  to  provide  for  a  large  crisis  expansion. 

"2.  The  newer  base  hospitals  here  have  a  capacity  of  from  2.000  to  3.000 
beds.    The  capacity  of  the  Casualty  Clearing  Stations  (U.  S.  Evacuation  Hos- 


756 


MODERN  MILITARY  SURGERY 


pitals)  varies  from  500  to  1,000  beds.  The  larger  size  has  the  following  ad- 
vantages: (a)  economy  in  operation;  (b)  development  of  a  strong  professional 
staff;  (c)  large  convoys  can  be  cared  for — the  sick  and  wounded  must  be  con- 
sidered on  a  wholesale  and  not  a  retail  basis. 

"3.    The  hospital  grounds  should  be  in  excess  of  present  needs  to  allow 
for  rapid  expansion  for  crisis  needs. 


Befucf?   for   vounded  non 
vulnerable    to  artillery 
/  AuiitlArfdodor 
2  StreUfierhtarert 
t  Jirtlcher 


(litr»tch«r-l>earer  f>fC') 


*>*4 


Two  dressing   stations  irvsUHed 
in  cellars 
1  ^isiiiant  doctor  jrxf  Ihe  di'iBngagod 
medical  staff  of  the   Unit 
To   one  of  tfitie     drtssin^ itilions 
li  added  an    installsti'on  of 
3hoi*er    bath. 


Dreiaing  station  end  infirmar/ 
Chief  dollar  and  all    the    rtse.r¥t 
medical   staff     Medical  ears 

Sanitary  jeetien  aulamohilt   evacuaL 
the   ambulances  to  clearing  itation 
from  where    the    wounded  are  dire<iad\ 
to  the  hoifiltals   of  the  interior 


Clearing  hospital  where   the 
wounded    awetiL    the  de/>arture 
of  the  tram    and  those  whose 
ro/idillon  fvsfgqrit^aied  re, 
there 


Cars    beton^ing  to  tin    group 
of  stretcher  .  tearerj     who 
evacuate     the    dressing 
stations    to  the  smbukrxei 


5pefi»l    imrriAyeablc 

ambulance    for     surgerf 

HOSPITAL  UNTRC    (  ""^"JZ"'' ) 
•mmorMbl*       ambulance     fcf  jeriauj 
'  ■  ■  »^         wounded 


Croup  of  diiisionarf  stretcher- iearer$ 
7  doctors  of  wich  6  nutiliariei 
ISO  stretcher  ■  litoren 
C5   eo/iducJorj 
22    eari 


4  ceMr/Mifcc. 


Detail  of  (Surgical  Field  Service. 

Shows  actual  organization  of  service  immediately  behind  the  trenches,  where  the  con- 
formation of  the  ground,  the  particular  character  of  the  fighting  and  the  strategic  necessities 
have  called  for  these  special  dispositions. 


''4.  The  hospitals  should  be  so  planned  that  patients  may  be  conveyed  to 
all  parts  on  wheels.  If  patients  must  be  carried,  there  is  always  the  chance, 
in  the  strain  of  a  crisis,  that  the  bearers  maj'  become  exhausted  and  the  whole 
system  break  down.  It  is  very  difficult  to  plan  for  receiving  and  caring  for 
say  800  patients  in  a  day,  yet  there  have  been  many  times  in  the  experience  of 
every  active  hospital  when  more  than  half  of  its  entire  capacity  was  thrown 


MODERN  MILITARY  SURGERY  757 

upon  it  in  a  day.  There  is  'feast  or  famine.'  Nothing  could  be  more  regrettable 
than  to  fail  to  provide  sufficient  capacity  for  emergencies. 

"5.  Crisis  expansion  is  splendidly  provided  for  in  British  hospitals  by  tents 
containing  closely-placed  rows  of  board  cots.  These  are  not  used  during  quies- 
cent periods,  but  are  filled  in  crises.  Emergencies  are  further  planned  for 
in  advance  by  the  continual  evacuation  of  patients  to  the  home  stationary 
hospitals. 

"6.  The  receiving  organizations  also  must  provide  for  crisis  expansion: 
(a)  It  should  be  so  arranged  that  the  entire  hospital  can  be  filled  within 
twenty-four  hours,  (b)  To  avoid  blockade,  the  point  of  exit  for  the  am- 
bulances should  be  opposite  the  point  of  entrance,  (c)  The  space  should  be  so 
arranged  and  the  reception  personnel — stretcher-bearers,  etc. — so  organized 
that  a  number  of  ambulances  can  unload  simultaneously,  and  the  patients  be 
distributed  to  their  cots  with  no  confusion  and  with  minimum  delay. 

"7.  The  casualty  clearing  hospital  is  the  bag  for  the  field  hospitals;  the 
base  hospital  for  the  casualty  clearing  hospitals.  Crises  must  be  planned  for  in 
advance  by  constant  evacuation  all  along  the  line." 

The  task  of  evacuating  the  wounded,  even  at  its  best,  is  a  complicated  one, 
and  there  is  no  other  class  of  military  work  which  undergoes  such  startling 
and  unexpected  variations.  For  this  reason  the  military  surgeon  must  not 
only  be  skillful  professionally,  but  he  must  be  a  man  of  above  the  average 
Bourage  and  resourcefulness. 

"Le  service  sanitaire,"  or  as  it  is  also  called,  the  "Service  de  sante,"  is 
the  French  organization,  under  the  ministry  of  the  war,  which  has  charge  and 
direct  control  of  everything  to  the  sick  and  wounded,  from  the  time  they  leave 
the  trench  or  firing  line,  on  through  the  various  intermediary  stages,  and 
until  they  are  discharged  from  treatment  at  a  base  or  auxiliary  hospital.  There 
are  two  distinct  branches  to  this  service,  one  being  called  the  "service  of  the 
advance,"  which  works  exclusively  in  the  zone  of  the  armies,  and  the  other 
being  called  the  "service  of  the  rear,"  which  later  takes  up  the  entire  medical 
and  surgical  work  of  the  "zone  of  the  interior."  The  following  table,  re- 
produced from  Fauntleroy's  report  to  the  United  States  Government  in 
November  1915,  shows  the  organization  and  disposition  of  the  sanitary  units 
and  formations  for  one  army  corps. 

The  French  Red  Cross,  or  "Croix  Rouge,"  is  a  society  of  considerable  pro- 
portions, even  in  times  of  peace,  with  ramifications  throughout  the  Republic, 
and  is  organized  along  the  lines  of  the  same  societies  in  the  United  States, 
England,  Germany  and  Russia.  It  is  supported,  as  in  this  country,  by  volun- 
tary aid  and  subscriptions,  and  since  the  outbreak  of  the  war  has  enormously 
increased  in  size  and  usefulness.  Indeed,  it  is  not  too  much  to  say  that  the 
continuous  efforts  put  forth  by  different  branches  of  this  society  are  largely 
responsible  for  the  comfort  of  the  soldiers  in  the  field  and  also  of  the  wounded 
in  the  many  hospitals  scattered  throughout  the  country. 

TREATMENT  OF  WOUNDS 

The  treatment  of  wounds  constitutes  the  greatest  single  problem  of  military 
surgery,  and  it  is  in  this  respect  that  eventful  advances  have  been  made  in  the 
practice  of  surgery.  Due  to  the  many  different  schools  concerned,  there  have 
been  a  large  number  of  ways  of  treating  wounds  on  the  battle-field  and  in  the 
base  hospitals.  However,  on  the  whole,  there  have  been  reported  much  better 
results  during  the  last  year  than  during  the  first  months  of  the  present  war. 


758  :\IODERN  MILITARY  SURGERY 

A  general  plan  of  treatment  as  accepted  by  the  majority  of  workers  is  as 
follows : 

1.  Primary  treatment — excision  of  the  parts. 

2.  Extraction  of  foreign  bodies. 

3.  Treatment  of  infection. 

4.  Secondary  sutnre. 

5.  Later  or  plastic  surger^^ 

Primary  treatment  of  wounds.  In  case  of  simple  perforation  of  the  soft 
parts  with  small  Avounds  of  entry  and  of  exit  produced  bj'  pointed  bullets,  no 
interference  is  necessarj^  or  desirable.  Tincture  of  iodine  should  be  applied  to 
each  wound  and  a  small  dry  dressing  applied.  It  is  the  practice  in  some  of  the 
hospitals  to  excise  the  injured  skin  about  the  small  wound  in  order  to  prevent 
a  small  amount  of  sloughing  which  sometimes  occurs. 

In  rifle-ball,  shrapnel  and  shell  wounds  which  demand  operation,  it  is 
now  the  practice  in  many  clinics,  although  by  no  means  universal,  to  excise 
those  tissues  which  have  been  damaged  by  the  projectile,  in  the  hope  of  remov- 
ing all  infection  and  all  devitalized  tissue.  The  incisions  should  be  complete 
enough  not  only  to  allow  for  liberal  drainage,  but  to  admit  of  the  removal  of 
all  foreign  material.  In  shell  wounds  the  ragged  tissue,  especially  fascia, 
should  always  be  removed  along  with  unattached  bone  and  foreign  bodies. 
Shrapnel  wounds  resulting  in  the  destruction  of  deep  tissues  are  to  be  similarly 
treated.  If  possible,  an  X-ray  plate  of  the  affected  part  should  be  obtained 
before  operation.  This,  however,  is  not  alwaj's  practicable,  as  sometimes  a 
large  number  of  wounded  will  arrive  at  the  same  time,  so  that  delay  for  an 
X-ray  plate  is  not  justifiable.  Fenestrated  rubber  tubing  is  in  more  or  less 
general  use  for  insuring  drainage,  although  a  few  instances  of  pressure 
necrosis  have  recently  been  reported  as  due  to  the  presence  of  the  foreign 
body  in  the  wound.  As  a  principle,  however,  it  is  always  best  to  interpose  an 
inert  substance,  such  as  rubber  or  glass,  in  order  to  maintain  drainage  during 
the  first  few  days  after  an  operation. 

Very  serious  results,  and  even  death,  are  often  produced  from  the  infection, 
unless  the  dead,  contused  tissue  is  unsparingly  cut  away,  foreign  bodies  re- 
moved, the  best  drainage  provided  by  means  of  rubber  or  gauze  wicks  wet  in 
sodium  hypochlorite  solution,  and  lightly,  but  effectually,  placed  into  every 
recess  of  the  wound  and  frequently  changed.  Above  all,  such  dressings  should 
not  be  "waterproofed"  with  rubber  tissue  or  other  impermeable  coverings, 
as  such  procedures  usually  result  disastrously  to  the  patient  because  of  the 
lack  of  drainage  thereby  produced.  Where  such  treatment  is  instituted 
promptly,  little  or  no  pus  forms,  foul  wounds  clean  themselves  quickly,  vigor- 
ous granulations  spring  up,  and  the  treatment  resolves  itself  merely  into  that 
of  a  large  granulating  wound.  Of  course,  all  such  cases  receive  antitetanic 
serum  immediately.  In  view  of  the  initial  destruction  of  tissue,  the  final 
deformity  is  often  surprisingly  slight. 

Treatment  of  infected  wounds.  According  to  Lloyd  IMills  (Amer.  Encycl. 
of  Ophth.,  Vol.  X.),  careful  clinical  and  bacteriological  study  of  battle  wounds 
has  solidly  established  the  following  facts : 

"1.  The  prevention  and  cure  of  infection  constitute  the  greatest  problem 
of  military  surgery. 

"2.  Little  or  no  bacterial  growth  occurs  in  projectile  wounds  during  the 
first  four  to  six  hours  following  injury.  Such  as  does  occur  comes  mainly 
from  implantation  of  organisms  with  the  projectile  or  secondary  missiles, 
and  where  these  wounds  can  be  effectually  opened  and  cleansed  of  foreign 
material  before  bacterial  growth  extends  to  and  into  the  surrounding  tissue, 
infection  does  not  occur,  or  is  almost  negligible. 

"3.    Wherever,    from   the  nature   of  the  wound,  it  is  possible  to  excise 


MODERN  MILITARY  SURGERY 


759 


the  bruised  and  contaminated  tissue  about  the  path  of  the  missile,  the  usual 
result  is  primary  union. 

"4.  If,  owing  to  faulty  transport,  excessive  casualties,  or  extreme  shell- 
shock  or  exhaustion,  prompt  surgical  care  is  impossible  and  infection  spreads 
to  all  parts  of  the  wound,  free  incision,  adequate  drainage,  the  use  of  light 
dressings  frequently  changed,  and  continuous  irrigation  offer  the  surest  means 
of  recovery." 

The  use  of  antiseptic  solutions  in  battle  wounds  has  undergone  much  re- 
vision as  the  result  of  the  brilliant  and  painstaking  researches  of  Almroth 
"Wright,  Carrell,  Dakin  and  many  others,  who  have  shown  the  uselessness  of 
merely  washing  pus  out  of  infected  wounds  without  directing  treatment  to  the 
walls  of  the  wound  where  the  delicate  biological  changes  of  tissue  resistance 
to  bacteriological  invasion  are  taking  place.  Two  solutions  stand  out  among 
the  many  advocated  for  continuous  irrigation  and  wet  dressing:  Wright's 
solution  of  5  per  cent,  sodium  chloride  with  1  per  cent,  citrate  has  for  its 
object  the  'lymph  lavage'  of  the  infected  tissue  by  introducing  this  fluid  of 
high  osmotic  properties  freely  into  every  part  of  the  wound,  while  Dakin 's 


tjr 


A  Perforating  Wound  with  Comminuted  Fracture  of  the  Upper  Arm. 

solution  of  sodium  hj^pochlorite,  similarly  employed,  is  an  effective  antiseptic 
without  the  albuminotropic  properties,  which  make  solutions  of  bichloride  of 
mercury  or  of  iodine  or  phenol  objectionable.  Dakin 's  solution  is  made  bj'' 
adding  200  grams  of  chlorinated  lime  to  5  liters  of  tap  water,  allowing  it  to 
macerate  over  night.  To  this  is  added  a  solution  of  100  grams  of  anhydrous 
sodium  carbonate  and  80  grams  of  sodium  bicarbonate  in  5  liters  of  cold  tap 
water;  the  mixture  is  stirred  vigorously  for  a  minute  and  then  the  calcium 
carbonate  is  allowed  to  precipitate.  After  a  half  hour,  the  supernatant  fluid 
is  filtered  through  a  paper  and  is  ready  for  use  without  heating. 

Lewis  A.  Stimson  {Jour.  Am.  Med.  Ass'n.,  p.  1687,  Dec.  2,  1916)  gives  the 
following  formula  of  Dakin 's  solution,  which  he  obtained  from  Dr.  Carrell  at 
Compiege  in  May,  1916 : 

1.    Chlorinated  lime    (bleaching  powder) 200  gm. 

Sodium  carbonate,  dry 100  gm. 

Sodium  bicarbonate   -. 80  gm. 


760  MODERN  MILITARY  SURGERY 

2.  Put  the  chlorinated  lime  in  a  12-liter  flask  with  5  liters  of  ordinary 
water,  and  let  it  stand  over  night. 

3.  Dissolve  the  sodium  carbonate  and  bicarbonate  in  5  liters  of  cold  water. 

4.  Pour  (3)  into  the  flask  containing  (2),  shake  it  vigorously  for  a  minute, 
and  let  it  stand  to  permit  the  calcium  carbonate  to  settle. 

5.  After  half  an  hour  siphon  ofl!  the  clear  liquid  and  filter  through  paper 
to  obtain  a  perfectly  limpid  product.  This  must  be  kept  protected  from  the 
light. 

The  antiseptic  solution  is  then  ready  for  use ;  it  contains  about  0.5  gm.  per 
cent,  of  sodium  hypochlorite  with  small  amounts  of  neutral  soda  salts;  it  is 
practically  isotonic  with  blood  serum.    It  should  meet  the  following  tests : 

Test.  Put  about  20  cc.  of  the  solution  in  a  glass  and  pour  on  its  surface 
a  few  centigrams  of  phenolphthalein  in  powder ;  shake  it  with  a  circular  move- 
ment, as  in  rinsing;  the  liquid  should  remain  colorless,  A  more  or  less  marked 
red  discoloration  indicates  the  presence  of  a  notable  quantity  of  free  alkali, 
or  incomplete  carbonation  inputable  to  an  error  in  technique. 

Errors  to  be  avoided.  Never  heat  the  solution.  If  in  an  emergency''  it  is 
necessary  to  triturate  the  chlorinated  lime  in  a  mortar,  do  so  only  with  water, 
never  with  the  solution  of  the  soda  salts. 

Tritration,  To  10  cc.  of  the  solution  add  10  cc.  of  distilled  water,  2  gm.  of 
potassium  iodid  and  2  cc.  of  acetic  acid.  Pour  into  this  a  mixture  of  deci- 
normal  (2.48  per  cent.)  solution  of  sodium  thiosulphate  (hyposulphite)  until 
it  is  decolorized.  The  number  of  cubic  centimeters  of  thiosulphate  employed 
multiplied  by  0.03725  equals  the  percentage  of  sodium  hypochlorite  in  the 
solution. 

The  efficacy  of  nearly  all  of  the  numerous  other  solutions  which  have 
been  urged  in  the  treatment  of  battle  wounds  depends  mainly  upon  their 
high  osmotic  properties.  Most  prominent  among  them  are  various  strengths 
of  sea  water  or  of  solutions  of  sea  salt ;  50  per  cent,  glucose ;  5  per  cent,  sodium 
benzoate ;  magnesium  hypochlorite ;  magnesium  sulphate,  advocated  by  Mori- 
son  and  Tulloch,  in  a  solution  of  40  ounces  of  the  salt  to  30  ounces  of  boiling 
water  and  10  of  glycerine ;  magnesium  chloride  in  1.2  per  cent,  solutions  of  the 
anhydrous  and  1.7  per  cent,  of  the  crystalline  salt  (Delbet  and  Karajano- 
poulo)  ;  and  finally,  Locke's,  Ringer's,  and  Schiassi's  artificial  serums,  urged 
with  much  enthusiasm  by  Soubeyran  as  nutrient  serums  during  the  reparative 
stage  of  wounds.  All  of  these  solutions  have  the  common  advantages  of 
comparative  painlessness  and  cheapness. 

Surgical  opinion  has  not  yet  crystallized  on  the  use  of  vaccines  in  the 
treatment  of  battle  wounds.  There  is  much  favorable  clinical  testimony, 
often  of  a  striking  nature,  and  in  doubtful  cases,  or  in  those  in  which  a  smear 
shows  streptococci,  a  prophylactic  injection  of  vaccine  containing  streptococci, 
staphylococci  and  the  bacillus  of  Welch  seems  indicated. 

Bismuth  paste  similar  to  the  preparation  introduced  by  Dr.  Emil  Beck  of 
Chicago  some  years  ago,  is  now  being  used  quite  extensively  for  the  treatment 
of  infected  suppurating  war  wounds. 

The  treatment  is  given  as  follows : 

1.  Under  an  anesthetic  the  wound  and  surrounding  skin  are  prepared  by 
swabbing  with  1-20  carbolic  acid  or  Avith  tincture  of  iodin. 

2.  The  wound  is  opened  freely  to  allow  of  inspection  of  its  cavity.  Portions 
of  macerated  tissues,  foreign  bodies,  clothing,  etc.,  are  removed.  In  so  doing 
special  regard  must  be  paid  to  nerve  trunks  and  muscular  branches  of  nerves, 
since  the  division  of  blood-vessels,  excepting  the  largest,  and  of  muscles  them- 
selves, does  little  harm  as  compared  with  that  of  the  disability  following 
nerve  damage. 

3.  Fill  up  the  entire  cavity  with  bismuth  paste,  dress  the  wound  with 


MODERN  MILITARY  SURGERY  761 

sterile  gauze,  and  apply  a  bandage.     This  dressing  requires  no  change  for 
several  days  if  the  patient  is  free  from  pain  and  constitutional  disturbance. 

Beck's  bismuth  paste  is  a  mixture  of  one  part  of  bismuth  subnitrate  in 
three  parts  of  yellow  vaseline.  This  mixture  has  proven  efficacious  in  a  large 
number  of  cases  of  subacute  or  chronic  inflammations  with  cavity  or  sinus 
formation.  Its  use  is  especially  indicated  in  old  tuberculous  abscesses  and  in 
osteomyelitis. 

The  British  and  French  have  recently  used  a  bismuth  iodoform  paste, 
called  ''Bipp,"  which  is  made  up  as  follows: 

Bismuth  subnitrate 8  oz. 

Iodoform   16  oz. 

Liquid  paraffin 8  oz.   (approx.) 

The  powders  are  mixed  together  in  a  mortar  and  the  liquid  paraffin  in- 
corporated. The  quantity  of  liquid  paraffin  required  varies  according  to  the 
bulk  of  the  powders,  the  bismuth  in  particular  being  liable  to  a  considerable 
variation  in  bulk.  A  sufficient  quantity  should  be  added  to  form  a  paste.  It 
is  then  advisable  to  rub  down  the  paste,  in  small  quantities  at  a  time,  on  a 
slab  with  a  spatula,  to  insure  freedom  from  grit  and  dry  particles  of  powder. 

Secondary  suture  may  be  defined  as  any  suture  of  a  wound  not  performed 
within  the  first  24  hours.  There  is  considerable  scope  for  it  in  the  surgery 
of  war  wounds,  where  large  granulating  surfaces  so  often  result,  either  from 
the  nature  of  the  injury  itself,  or  from  extensive  incisions  called  for  in  the 
course  of  treatment. 

Successful  suture  saves  time — sometimes  many  weeks  or  even  months ;  it 
also  obviates  to  a  large  extent  the  pain  and  disability  resulting  from  adherent 
cicatrices.  A  careful  bacteriological  examination  of  the  wound  must  be  made 
before  attempting  to  close  it  up.  There  should  not  be  more  than  one  or  two 
organisms  to  the  field  of  the  microscope  in  a  smear  made  from  the  surface 
of  the  wound.  Any  wound  may  be  closed  in  this  manner  provided  that:  (1) 
the  skin  edges  come  together  without  undue  tension;  (2)  the  surrounding  skin 
is  healthy;  (3)  the  wound  surfaces  can  be  approximated  so  as  to  obliterate 
all  dead  spaces;  (4)  the  bacteriological  report  is  favorable.  Deep  silkworm- 
gut  sutures  are  used  which  at  once  bring  together  the  deep  tissues  and  the 
skin,  without  the  formation  of  pockets. 

Paraffin  treatment.  There  has  been  introduced  since  the  first  months  of 
1917  a  new  and  useful  treatment  for  the  open  granulating  wounds  so  often 
seen  in  the  convalescent  stages.  Heretofore  it  has  usually  required  weeks, 
and  sometimes  months,  for  these  granulating  surfaces  to  become  clean  and 
epidermized.  In  cases  of  extensive  infected  wounds  which  are  too  broad  and 
too  shallow  to  allow  of  secondary  suture,  these  wounds  are  cleaned  first  by 
one  of  the  methods  previously  described,  so  that  there  are  but  very  few  or 
no  organisms  present  in  smears  made  from  the  wound  secretion.  A  mixture 
containing  paraffin  is  then  applied  in  the  following  manner:  The  mixture  is 
heated  over  a  water-bath  until  it  is  just  melted  and  a  layer  painted  upon  the 
surface  of  the  wound  to  its  edges  by  means  of  a  fine,  broad  camel's  hair  brush. 
A  very  thin  (2-3  mm.)  layer  of  absorbent  cotton  is  next  applied  over  the 
paraffin,  then  another  layer  of  paraffin,  and  then  cotton,  until  three  to  four 
layers  have  been  applied.  This  dressing  is  left  in  place  for  24  hours,  when  it 
is  peeled  ofi:'  and  another  similar  dressing  applied.  By  this  method  wound 
surfaces  are  rendered  clean,  the  granulations  become  healthy,  the  epithelium 
grows  more  rapidly,  and  the  part  is  placed  in  good  condition  for  skin-grafting, 
if  necessary.  An  additional  advantage  of  the  dressing  is  in  the  absence  of  pain. 
The  patients  so  treated  are  rendered  quite  comfortable. 

Several  different  mixtures  have  been  used  in  the  present  war,  one  of  which, 


762  MODERN  MILITARY  SURGERY 

called  ' '  Ambrol, ' '  has  been  very  successfully  employed  by  H.  C.  Schumm  in 
Vienna,  who  has  introduced  it  in  our  clinic.    It  is  made  up  as  follows : 

Paraffin 12  parts. 

Yellow  beeswax 1  part. 

Resin  cereate   i/2  part. 

This  mixture  is  heated  over  a  water  bath  just  before  using  as  described 
above.  The  paraffin  should  be  of  good  grade  with  a  low  melting  point.  Where 
such  a  grade  of  paraffin  cannot  be  obtained,  a  small  amount  of  liquid  paraffin 
may  be  added  which  answers  practically  the  same  purpose  in  lowering  the 
melting  point.  The  paraffin  used,  according  to  Leech,  should  be  liquid  at  or 
below  50°  C.  and  a  thin  film  should  be  pliable  at  28°  C.  and  ductile  at  31°  C. 
Gas-bacillus  infection.  Before  the  principles  of  early  cleansing  of  wounds, 
free  drainage,  and  continuous  irrigation,  were  clearly  established  in  the  present 
war,  the  incidence  and  mortality  of  tetanus  and  gas-bacillus  infection  were 
appalling.  Bruce  in  his  early  work  reported  a  mortality  of  57.7  per  cent, 
out  of  231  cases. 


Gas  Bacillus  Infection. 

Spread  of  bacilli  across  the  muscle  along  the  track  of  the  large   vessels,  and  longitudinally 
between  the  musc-le  fibrils  along  the  capillaries.     Note  absence  of  leucocytes. 

A  recent  contribution  by  Judd  upon  this  subject  is  here  given  in  summary : 
Modern  trench  warfare  with  the  accompanying  difficulties  in  providing  cleanli- 
ness, exposes  a  large  proportion  of  wounded  to  the  dangers  of  gas-bacillus 
infection.  The  majority  of  these  cases  show  shell  wounds  where  a  piece  of 
contaminated  clothing  was  carried  into  the  depths  of  the  wound  by  the  pro- 
jectile. Among  the  varieties  of  micro-organisms  in  the  wounds,  the  bacilli 
perfringens  are  generally  accepted  as  causative  organisms.  These  bacilli  ap- 
pear in  the  wound  from  the  ninth  to  the  twelfth  hour.  The  aerobic  bacteria 
appear  about  the  forty-eighth  hour.  The  symptoms  of  the  infection  appear 
early,  usually  on  the  second  day.  The  parts  of  the  body  most  often  affected 
are  the  legs,  on  account  of  the  likelihood  of  their  becoming  contaminated  by 
dirt  and  fecal  matter. 


MODERN  MILITARY  SURGERY 


768 


It  is  of  vital  importance  that  the  diagnosis  be  made  early.  Pain,  swelling 
and  tension  of  the  wound,  with  rapidity  of  the  pulse,  are  important  early 
symptoms.  Vesicles,  discoloration  of  the  skin,  gas-formation  and  odor  should 
be  considered  later  symptoms.  The  prognosis  depends  upon  whether  the 
patient  receives  proper  early  treatment.  Trench  hygiene  and  personal  clean- 
liness are  vital  prophylactic  measures.  Early  incision  of  the  wound  with  re- 
moval of  the  foreign  bodies,  cleansing  of  the  wound,  and  excision  of  damaged 
tissue  doomed  to  slough,  are  the  correct  surgical  procedures  of  prevention. 
When  the  infection  is  once  established,  well-placed,  deep  incisions,  exposing 
the  deeper  tissue  to  the  air,  are  indispensable.  For  the  clinical  treatment  of 
the  wound,  Dakin's  solution  has  given  the  best  results. 


The  Microscopic  Appearance  of  Gas  Gaxgeexe  in  Segmented  Muscle. 

Showing  the  total  destruction  of  tissue  in  the  central  portion   which  is  crowded  with  bacilli 

and  leucocytes. 


Gas-bacillus  infection  has  proven  one  of  the  worst  dreaded  of  the  late 
conditions  seen  in  the  base  hospitals,  particularly  in  France  and  Germany, 
and  although  there  has  been  a  marked  decrease  in  the  disease,  the  mortality 
remains  almost  as  high  as  at  the  beginning  of  the  war.  The  virulence  of  these 
infections  is  usually  so  great,  and  is  evidenced  by  such  rapid  growth,  that 
the  patient  has  a  very  poor  outlook,  as  a  rule,  from  the  beginning.  When 
such  infection  begins  in  an  extremity,  some  men  prefer  to  amputate  at  once, 
because  of  their  lack  of  faith  in  any  radical  treatment  short  of  total  excision 
of  the  part.  There  is  no  doubt,  however,  that  free  incision  with  thorough 
drainage  and  proper  antiseptic  precautions  instituted  early,  will  in  most 
instances  abort  the  disease. 

Tetanus  infection.  One  of  the  most  brilliant  results  of  the  work  of  the 
sanitary  services  of  the  different  armies  has  been  the  enormous  reduction  in 


764  MODERN  MILITARY  SURGERY  I 

> 

incidence  and  mortality  of  tetanus  bacillus  infection.  At  present  all  cases 
of  open  wounds  caused  by  rough  fragments,  upon  arrival  at  the  hospital,  are 
given  prophylactic  doses  of  tetanus  antitoxin.  The  dosage  varies  from  5U0  to 
2,000  units,  with  a  probable  average  of  about  1,000  units.  The  danger  of 
anaphylactic  shock  is  said  to  be  negligible  when  anaphylactic  doses  of  500 
U.  S.  A.  units,  contained  in  3  cc.  of  horse  serum,  are  administered  subcu- 
taneously,  no  matter  what  the  interval  after  the  preceding  injections.  The 
same  precautions  should  be  observed  in  the  open  treatment  of  wounds  or  in- 
fections, as  in  gas-bacillus  or  other  virulent  infections. 

When  a  case  has  developed  the  signs  or  symptoms  so  well  recognized  of 
tetanus,  it  is  best  to  give  at  once  massive  doses  of  tetanus  antitoxin.  These 
should  be  given  subcutaneously  and  intravenously,  5,000  to  10,000  units  in  the 
area  surrounding  the  wound.  A  lumbar  puncture  should  then  be  made  and 
from  30  to  40  cc.  of  cerebrospinal  fluid  allowed  to  escape,  after  which  is  in- 
jected 10,000  to  20,000  concentrated  units.  Even  higher  doses  than  these  are 
advocated  by  some,  such  as,  in  some  instances,  90,000  to  100,000  units.  Clinical 
evidence  points  to  the  fact  that  the  curative  value  of  tetanus  antitoxin  de- 
pends upon  the  amount  of  the  antitoxin  which  is  given  at  the  very  onset  of 
the  symptoms.  There  have  been  reported  a  greater  proportion  of  recoveries 
when  large  massive  doses  were  used  as  soon  as  the  symptoms  were  noted. 

FOREIGN  BODIES 

The  question  as  to  whether  retained  bullets  should  or  should  not  be  re- 
moved has  been  discussed  at  great  length  by  a  large  number  of  workers.  The 
predominant  opinion,  however,  is  that  foreign  bodies  should  be  removed  if 
possible  at  the  first  operation.  This  is  particularly  true  of  large,  ragged,  metal- 
lic fragments,  because  these  tend  to  prevent  the  complete  healing  of  an  infected 
wound.  Occasionally,  however,  bullets  are  found  imbedded  in  soft  tissues, 
such  as  the  muscles,  where  they  produce  absolutely  no  symptoms.  Even  in 
these  cases,  it  is  found  that  the  patient  is  usually  extremel^^  desirous  of  having 
the  bullet  removed  because  of  his  knowledge  of  its  presence.  However,  when 
the  localization  of  a  bullet  is  liable  to  require  so  much  traumatism  in  the 
field  of  an  infected  wound,  it  is  best  to  first  treat  the  infection  and  later  re- 
move the  object,  because  of  the  danger  of  reinfecting  fresh  portions  of  tissue. 

Localization  of  foreign  bodies.  No  single  accurate  method  has  been  ad- 
vocated and  used  for  the  finding  of  various  forms  of  missiles  deeply  imbedded 
in  the  tissues.  When  composed  of  metal,  the  X-raj^  is,  of  course,  a  necessary 
adjunct  in  finding  and  localizing  a  foreign  body.  The  great  disadvantage, 
however,  has  been  in  a  tendency  to  make  the  procedure  with  the  X-ray  alto- 
gether too  complicated  and  intricate.  Many  so-called  exact  and  scientific 
methods  have  been  devised,  which  often  are  less  accurate,  require  more  time, 
and  are  much  more  expensive  than  the  simpler  methods.  It  is  a  general  rule 
in  surgery  that  when  an  object  can  be  attained  by  one  of  two  methods,  a  simple 
and  a  complex,  the  former  should  always  be  chosen. 

There  are  three  good  simple  ways  of  localizing  these  missiles.  The  first, 
and  probably  the  most  extensively  used,  is  that  of  making  two  radiographs, 
each  of  whose  plane  is  at  right  angles  with  the  other.  This  method  is  satis- 
factory in  practically  all  cases  of  injuries  to  the  extremities,  but  usually  does 
not  apply  to  such  portions  of  the  anatomy  as  the  hip.  abdomen,  or  other 
parts  of  the  trunk.  This  method  is  the  one  in  most  common  use  in  France 
and  England.  A  second  method  is  that  of  stereoscopic  radiography,  and  this 
method  has  proved  very  successful  in  most  instances.  There  is  the  disad- 
vantage, however,  that  a  thoroughly  stereoscopic  effect  is  not  always  produced 


MODERN  MILITARY  SURGERY  765 

upon  the  plates,  and  also  that  some  individuals  do  not  visualize  the  plates 
stereoscopically. 

A  method  which  seems  to  us  the  most  practical  and  consistent  is  the  fol- 
lowing : — The  patient  is  brought  to  the  X-ray  room  and  all  preparations  made 
for  the  operation  to  be  performed  there.  A  fluorescent  screen  is  then  inter- 
posed between  the  patient  and  the  eyes  of  the  operator  or  one  of  his  assistants. 
This  is  best  done  bj^  means  of  the  apparatus  devised  by  Bettman,  and  called 
a  "cryptoscope."  This  consists  of  a  light-tight,  cardboard  box  the  shape  of 
a  truncated  pyramid,  held  over  the  surgeon's  eyes  by  means  of  a  strap.  The 
base  of  the  pyramid,  which  is  18  x  13  cm.  in  size,  is  composed  of  a  fluorescent 
screen  which  is  on  a  hinge  and  when  released  from  a  catch  by  pressure  on  a 
button  flies  open  under  the  influence  of  a  spring.  A  piece  of  lead  glass  is 
inserted  into  the  box  to  act  as  a  shield.  When  the  base  is  pulled  down  into 
position,  the  surgeon  is  looking  into  a  light-tight  box,  upon  a  fluorescent 
screen.  A  very  simple  method  for  making  rough  localizations,  especially  in 
the  extremities,  is  simply  to  fiuoroscope  the  parts  in  as  nearly  as  possible  a 
perpendicular  direction,  marking  the  projections  of  the  foreign  body  on  the 
skin  with  blue  pencil.  Another  common  and  very  satisfactory  method  is  to 
rotate  the  patient  under  the  fiuoroscope,  keeping  the  distance  from  the  bullet 
to  the  skin  in  mind  and  ascertaining  where  this  is  the  smallest.  This  distance 
is,  for  all  practical  purposes,  the  depth  of  the  bullet.  Then  with  a  skin- 
marking  pencil,  the  site  of  the  bullet  is  indicated,  by  encircling  the  skin  with 
a  pencil  held  parallel  to  the  screen.  The  pencil  point  marks  the  site  of  the 
bullet  when  the  whole  pencil  is  outside  of  the  shadow  of  the  soft  parts. 

Eastman  and  Bettman 's  method  of  actual  removal  of  foreign  bodies  by 
means  of  the  cryptoscope  is  as  follows:  "The  presence  of  the  bullet  is  deter- 
mined by  the  method  just  described.  The  path  of  attack  has  been  planned, 
the  skin  area  prepared  in  the  usual  manner,  and  the  patient  placed  on  the 
X-ray  table  as  upon  an  operating  table.  A  tube,  preferably  a  Coolidge  tube, 
is  placed  under  the  table  stage.  The  field  of  operation  is  lighted  by  day- 
light or  strong  artificial  light.  The  cryptoscope  is  covered  by  a  sterile  cloth 
and  placed  over  the  eyes  of  one  of  the  assistants.  He  closes  the  screen  on  the 
base  of  the  apparatus,  the  X-ray  machine  is  set  in  function,  and  the  assistant 
may  localize  the  bullet  as  he  would  with  the  aid  of  the  usual  fluorescent  screen 
in  a  dark-room  by  means  of  a  metal  instrument.  The  surgeon  makes  a  small 
incision,  working  down  to  the  bullet,  being  guided  by  the  assistant  who  is 
watching  the  operation  on  the  fiuoroscope,  and  who  guides  him  verbally  or  by 
means  of  a  pointer  down  to  the  bullet.  It  will  often  happen  that  after  the 
incision  has  been  made,  the  assistant  himself,  by  blunt  dissection  with  a  forcep 
can  separate  the  tissues  and  grasp  the  bullet.  He  sees  the  silhouetted  clamp 
approach  the  metal  shadow.  He  sees  this  shadow  move  with  every  little  im- 
pulse of  the  clamp  when  he  has  reached  it.  As  he  opens  the  clamp  slowly,  he 
can  see  the  jaws  stretch  over  the  bullet.  He  can  see  that  he  has  grasped  the 
bullet.  He  then  releases  the  screen,  and  in  full  light  very  carefully,  so  as  not 
to  cause  any  injury  tp  neighboring  tissues,  he  withdraws  the  bullet.  Great 
care  must  be  taken  in  doing  this.  *  *  *  Often  in  simple  cases  the  surgeon 
himself  wears  the  cryptoscope,  operating  with  the  screen  released  and  orient- 
ing himself  from  time  to  time  by  closing  the  same  and  working  at  the  bullet 
with  the  fiuoroscope.     *     *     * 

"The  results  have  been  striking  in  many  cases.    Bullets  for  which  a  long 
search  has  been  made  after  repeated  searches,  have  been  quickly  removed 


766  MODERN  MILITARY  SURGERY 

when  the  search  was  aided  by  the  cryptoscope.  Time  and  again  the  surgeon 
was  unable  to  find  the  bullet  until  the  roentgenologist  pointed  to  the  location 
of  the  bullet  in  the  walls  of  a  wound,  or  under  a  retractor.  The  average  time 
for  a  foreign  body  operation  has  been  reduced  fifty  to  seventy-five  per  cent. 
Tissues  are  not  needlessly  traumatized,  nor  are  large  wounds  made  where  small 
ones  suffice.  We  have  also  used  this  method  with  similar  success  in  a  few 
cases  of  needles  in  the  hands  of  some  of  our  hospital  servants,  and  warmh^ 
recommend  its  use  for  such  cases." 

AMPUTATIONS 

]\Iany  limbs  are  now  being  saved  in  military  surgery  that  in  previous  wars 
were  amputated.  The  reason  for  this  is  that  by  the  modern  treatment  of 
wound  infections  and  bone  lesions  the  prognosis  is  much  more  favorable  than 
formerly.  Even  during  the  present  great  war  there  has  been  noted  a  marked 
decrease  in  mortality  following,  and  in  the  number  of  cases  of,  amputation  of 
limbs.  In  the  ^1,800  wounded  treated  by  Proust  in  1915,  there  were  152  plane 
section  amputations  with  a  mortality  of  15  per  cent.,  distributed  as  follows : 

52  thigh  amputations     47  per  cent,  mortality. 

31  leg  "  16     " 

9  foot  "  18     " 

29  arm  "  27     " 

18  forearm        "  55     " 

The  mortality,  however,  has  markedly  decreased  under  better  conditions, 
so  that  it  now  averages  only  about  8  per  cent. 

In  the  hospitals  at  the  front  during  the  first  few  months  of  the  war,  there 
were  horrifying  aiecounts  of  the  ravages  of  gaseous  gangrene,  and  of  the 
appalling  results  of  amputation.  The  condition  is  rarely  seen  at  the  base,  due 
to  the  good  work  of  the  clearing  hospitals ;  but,  in  the  early  days,  it  was  quite 
common.  Patients  were  received  at  the  base  hospitals  with  large  segments 
of  the  limb,  often  above  the  elbow  or  knee,  in  a  totally  gangrenous  condition, 
and  a  large  area  of  the  limb  was  hard  and  brawny,  with  the  typical  brown 
discoloration  frequently  extending  to  the  trunk.  Even  as  severe  a  condition 
as  this  is  amenable  to  circular  or  flapless  amputation,  when  done  early  enough. 

Gaseous  gangrene.  In  these  cases  there  is  a  spreading  infection,  often  of 
most  appalling  virulence.  Part  of  the  limb  is  gangrenous  and  crepitatinjr. 
often  with  gas-containing  bulla?  in  the  skin,  and  beyond  this  part  is  an  infil- 
trated edematous  area,  with  a  yellowish-brown  staining  of  the  skin,  which 
rapidly  becomes  involved  in  the  gangrenous  process.  Often  no  healthy  skin 
is  left  on  the  limb,  and  experience  has  shown  that  flaps  cut  from  the  threatened 
tissue  almost  invariably  slough  and  become  the  starting  point  of  a  further 
spreading  infection.  If,  on  the  other  hand,  a  flapless  amputation  is  done, 
close  to  the  edge  of  the  gangrenous  parts,  recovery  of  the  threatened  tissue 
is  the  rule,  and  not  only  is  life  saved,  but  a  maximum  econom.y  of  the  limb  is 
achieved. 

Especially  important  cases  are  those  in  which  the  gangrene  is  close  but  not 
up  to  the  knee,  hip  and  shoulder  joints.  In  gangrene  reaching  to  just  below 
the  knee — a  very  common  variety — a  flap  amputation,  to  be  safe,  would  need 
to  be  through  the  middle  or  upper  third  of  the  thigh.  If.  however,  the  skin 
can  be  divided  just  below  the  knee  and  the  bones  sawed  below  the  tubercle 


MODERN  MILITARY  SURGERY 


767 


Flapless  Amputatiox. 

Showing  an  amputation  stump  of  a  ease  of  progressive  emphysematous  necrosis  (gas-bacillus) 
infection  with  adhesive  straps  applied  for  traction  upon  the  skin. 


Flapless  Amputation. 

The   completed   dressing   and   apparatus   for   skin   traction   in   position   in   the    same    case   as 

preceding  illustration. 


768 


MODERN  MILITARY  SURGERY 


of  the  tibia,  there  is  little  retraction  of  the  skin,  since  the  quadriceps  and 
hamstrings  are  intact,  and  there  is  plenty  of  material  for  a  trans-condylar 
amputation  later.  Similarly,  at  the  hip-joint,  a  transverse  amputation,  which 
is  practically  the  first  stage  of  an  Esmarch  amputation,  often  saves  the  situa- 
tion, v^^hile  the  mortality  from  disarticulation  at  the  hip- joint  is  so  great  as  to 
make  it  almost  unjustifiable ;  and  at  the  shoulder,  it  can  be  used  as  the  first 
stage  of  a  shoulder-joint  amputation,  when  immediate  disarticulation  would 
be  much  more  risky. 


Flapless  Amputation. 

The  same  ease  as  the  preceding  showing  the  improvement  in  skin  growth  over  the  stump  at 

the  end  of  two  weeks. 


Compound  commiimted  fracture.  These  cases  in  war  wounds  due  to  shells 
differ  from  those  one  encounters  in  civil  practice.  In  the  compound  fractures 
we  are  accustomed  to  treat  in  peace  time,  the  protruding  bone  is  perhaps 
infected,  but  the  infection  is  usually  not  severe  and  is  confined  to  the  protrud- 
ing bone  and  the  immediate  focus  around  it — that  is,  it  is  strictly  localized. 
In  gunshot  fractures,  on  the  other  hand,  a  piece  of  metal  enters  the  limb, 
carrying  with  it  pieces  of  clothing  coated  with  mud  from  a  highly  manured 
soil;  it  strikes  the  bone  with  explosive  violence,  splintering  perhaps  five  or 
six  inches  of  the  shaft  and  lacerating  the  soft  tissues  widely;  and  the  exit 
wound  is  an  enormous  rent  made  by  pieces  of  bone  as  well  as  the  projectile. 
This  area  of  broken  bone  and  lacerated  tissue  and  blood-clot,  perhaps  as  large 
as  a  cocoanut,  is  at  once  infected  with  anaerobic  and  pyogenic  organisms. 

In  these  conditions,  local  cleansing  at  the  earliest  possible  moment  and 
free  drainage  do  what  they  can;  when  these  fail,  and  the  patient's  life  is  in 
danger,  amputation  is  called  for.  In  such  a  case  the  infection  is  very  wide- 
spread ;  the  whole  limb  is  edematous,  and  a  flapless  amputation,  at  or  above 
the  site  of  fracture,  is  the  best  treatment. 


MODERN  MILITARY  SURGERY  769 

Multiple  wounds.  These  are  fairly  common  in  later  war  surgery,  and  are 
usually  the  result  of  bomb  injury.  It  often  happens  that  a  hand  or  a  foot  is 
mangled  almost  beyond  recognition,  and  that  the  rest  of  the  limb  is  literally 
peppered  with  fragments,  every  one  of  them  causing  a  septic  wound.  Here  a 
flap  amputation  is  out  of  the  question,  and  a  simple  transverse  section  of  the 
limb,  with  a  cleansing  up  of  the  septic  area,  is  the  best  course. 

Fitzmaurice-Kelly  believes  that  the  flapless  amputation  is  best  because, 
(1)  it  saves  life  and  length  of  limb;  (2)  the  risk  of  secondary  hemorrhage  is 
lessened  and  arrests  the  spread  of  infection,  whereas  in  flap  amputations  sepsis 
often  recurs  in  the  flaps  and  spreads  up  from  their  base;  and  (3)  it  is  often 
practicable  where  no  other  method  is  possible. 

Technique.  The  methods  of  making  the  flap  amputations  are  so  well  known 
that  only  the  circular  amputation  will  be  described  here. 

The  skin  and  deep  fascia  are  divided,  usually  in  circular  fashion,  but 
sometimes  more  skin  can  be  utilized  by  making  the  incision  oblique.  After 
retraction  has  occurred  the  muscles  are  divided  at  the  level  of  the  retracted 
skin,  not  too  quickly,  so  as  to  allow  a  retraction  of  the  layers ;  then  the  bone 
is  sawed  flush  with  the  muscle,  the  vessels  are  ligated  and  the  nerves  carefully 
shortened.  The  surface  is  slightly  concave  at  first,  if  the  operation  has  been 
properly  done,  but  soon  becomes  convex  from  further  retraction.  This,  how- 
ever, once  the  part  is  fairly  clean,  is  easily  overcome  by  extension  from  adhesive 
strips  placed  above  the  wound.  In  this  way  the  loss  by  retraction  may  be 
made  up  and  it  is  usually  not  necessary  later  to  do  more  than  remove  a  length 
of  bone  from  the  shaft. 

CRANIAL  INJURIES 

General  consideration  of  projectile  injuries  of  the  skull  and  brain.  Pro- 
jectile wounds  of  the  cranium  have  long  been  divided  into  tangential  wounds, 
which  are  notable  for  the  amount  of  cortical  destruction  which  they  produce  and 
the  relative  frequency  with  which  they  are  survived;  penetrating  ivounds,  with 
lodgment  of  the  missile,  and  perforating  wounds,  in  which  the  missile,  practically 
always  a  rifle  bullet,  has  passed  through  and  emerged  from  the  skull. 

The  experiences  of  recent  wars,  but  more  particularly  of  the  present  con- 
flict, have  been  so  enormous,  however,  and  the  effects  of  wounds  of  certain 
cortical  regions  so  constant  in  their  symptomatology,  that  subdivisions  of 
cranial  wounds,  according  to  the  region  involved  or  the  symptoms  produced, 
are  necessary. 

The  great  number  of  points  in  the  brain  at  Avhich  the  optic  centers  and 
connections  may  be  wounded  or  involved  makes  necessary  a  brief  study  of 
cranial  wounds  in  general,  their  treatment  and  results. 

The  signs  and  symptoms  of  projectile  injuries  of  the  cranium  are  identical 
with  those  of  all  similar  skeletal  injuries  (bleeding,  pain,  dislocation  and 
functional  disturbance  resulting),  but  being  kept  more  or  less  in  the  back- 
ground by  the  symptoms  of  injury  of  the  brain  or  its  envelopes.  Every  pro- 
jectile wound  of  the  cranial  vault,  whether  this  is  fractured  or  not.  affects  the 
underlying  brain,  which  reacts  to  insult  like  all  other  tissue  and  to  a  degree 
corresponding  to  the  extent  of  the  trauma.  "Where  no  fracture,  or  merely  a 
slight  depressed  fracture,  has  occurred,  the  reactive  edema  of  the  meninsreal 
tissues,  the  cortex  and  the  subcortex  causes  the  brain  to  swell  and  to  tend  to 
become  too  large  for  the  skull,  even  in  the  absence  of  local  hemorrhage.  This 
is  further  exaggerated  by  the  presence  of  an  actual  serous  meningitis  when 
the  reactive  inflammation  becomes  excessive.  "With  severer  trauma  this 
edema  is  complicated  by  arterial  hemorrhage,  laceration  of  the  venous  sinuses 
with   hemorrhage,    thrombosis    and    obstructive    edema    of   the   cortex,    and 


770  MODERN  MILITARY  SURGERY 

mechanical  damage  of  all  degrees  to  the  nerve  elements  and  their  mutual 
associational  connections.  Intracranial  suppuration  is  the  cause  of  death  or  of 
further  disablement  in  nearly  all  cases  which  survive  the  initial  injury. 

The  amount  of  immediate  functional  disturbance  depends  on  the  location 
of  the  injury  not  less  than  on  its  extent,  for  certain  portions  of  the  brain, 
notably  the  frontal  regions,  are  amazingly  tolerant  of  physical  insult,  v^hile 
the  array  of  recoveries,  as  to  life  and  to  a  lesser  degree  as  to  vision,  after 
tangential  shots  of  the  occipital  region,  is  already  formidable. 

A  number  of  cases  of  complete  recovery  after  through-and-through  per- 
forations of  the  skull  have  been  reported  and  the  cases  of  penetraition  and  lodg- 
ment in  nearly  all  parts  of  the  brain  by  all  sorts  of  missiles,  which  have 
recovered  to  a  more  or  less  good  condition,  without  or  after  operation,  are 
many. 

The  study  of  the  late  results  in  these  cases  of  brain  injury  is  disappointing, 
but  it  is  altogether  probable  that  the  present  era  of  finished  plastic  surgery  in 
the  closure  of  cranial  defects  and  the  prevention  of  large  cerebral  scars  w^ill 
go  far  toward  averting  the  constant  headaches  and  the  undue  sensitiveness  to 
sunshine  which  are  the  common  and  enduring  results  of  nearly  all  these  in- 
juries. It  wall  also  radically  lessen  the  frequency  of  cortical  and  subcortical 
softening,  cyst  formation,  unduly  large  cerebral  scars,  the  various  forms  of 
Jacksonian  epilepsj^  and  the  chronic,  diffuse  or  localized  meningo-encephalitis 
w^hich  appears  so  insidiously  within  a  few  wrecks  or  months,  and  which  may 
lead  to  death  through  sudden  and  unheralded  coma,  or  gradually,  after  a 
prelude  of  sphincter  troubles  and  mental  disturbance.  Psychological  research 
after  this  form  of  cranial  injury  often  discovers  latent  psychic  defects  in 
surprising  ways. 

Lapointe  {Jour.  Amer.  Med.  Ass'n.,  July  31,  1915,  p.  441)  declares  that  the 
immediate  seriousness  of  cranial  wounds  in  cases  that  survive  to  reach  hospital 
care  depends  on  the  continuity  of  the  dura.  If  this  is  intact,  the  immediate 
mortality  is  about  7  per  cent.,  as  opposed  to  a  mortality  of  56  per  cent.,  due 
to  infection  in  nearly  every  case  in  which  the  brain  substance  is  involved. 

Joseph  {Milnchen.  med.  Wchnschr.,  Aug.  31,  1915)  is  so  much  of  the  same 
opinion  that  he  divides  cranial  wounds  into  those  with  intact,  and  those  with 
perforated  dura.  In  this  connection  it  is  astonishing  to  see  the  extent  to 
which  the  dura  can  withstand  destruction  of  the  overlyinsr  bone,  Avhich  may  be 
completely  comminuted  over  wide  areas  and  yet  without  dural  laceration, 
although  the  brain  beneath  may  or  may  not  be  extensively  destroyed. 

Viewed  from  the  combined  clinical,  anatomical  and  operative  standpoints, 
the  most  significant  classification  of  projectile  cranial  w^ounds  in  general  seems 
to  be: 

1.  Scalp  wounds,  without  definite  external  signs  of  fracture  of  the  skull. 

2.  Depressed  fracture,  without  injury  to  the  dura. 

3.  Fracture  involving  the  dura,  but  without  infection  or  lodgment  of 
foreign  bodies. 

4.  Fracture  involving  the  dura,  with  infection  and  with  foreign  bodies  in 
the  brain. 

5.  Fractures  and  fissures  of  the  cranial  fossas,  either  complicating  frac- 
ture of  the  vault  or  as  the  result  of  direct  injury. 

"When  the  skull  is  fractured,  the  inner  table  suffers  far  more  severely  than 
the  external.  As  a  rule,  and  accordingly,  every  fracture  of  the  skull,  regard- 
less of  its  apparent  triviality,  should  be  considered  as  associated  with  com- 
minution and  depression  of  the  inner  table  and  with  the  consequent  damage 
to  the  dura,  the  meningeal  vessels  and  the  venous  sinuses. 

The  immediate  consequences  of  fracture  of  the  vault  are  exemplified  by 
concussion,  compression  and  irritation  of  the  brain.    Patients  with  depressed 


MODERN  MILITARY  SURGERY  771 

fractures  are  often,  though  not  always,  unconscious  for  a  few  moments  imme- 
diately after  the  injury,  but  are  often  able  to  walk  considerable  distances 
within  a  short  time.  Headache,  in  all  instances  due  to  a  pathological  rise  in 
intracranial  pressure  as  the  result  of  the  traumatic  edema  of  the  bruised  brain, 
is  an  almost  constant  and  frequently  distressing  symptom  which  may  demand 
one  or  repeated  lumbar  punctures  for  its  relief. 

Progressive  hemorrhage  is  a  condition  of  great  rarity  among  cranial 
wounds  in  which  the  initial  injury  is  survived,  and  when  it  does  occur,  its 
cause  is  not  uncommonly  found  in  the  existence  of  fissures  running  to  parts  of 
the  skull  remote  from  the  point  of  direct  injury. 

Very  often  the  only  sign  of  intracranial  damage  in  these  cases  of  projectile 
wounds  is  persistent  injection  of  the  optic  discs,  without  swelling,  and  the 
exact  nature  of  the  damage  is  disclosed  by  an  exploration  or  revision  of  the 
scalp  wound,  after  the  X-ray  findings  have  corroborated  the  ophthalmoscopic 
evidence. 

Both  pulse  and  temperature  curves  are  notoriously  unreliable  after  crania] 
injuries.  Early  absence  of  frank  fever  is  common  in  secondary  brain  abscesses, 
and  on  the  other  hand  a  pulse  of  normal  rate  may  actually  be  a  pressure  pulse 
concealed  by  the  toxic  effects  of  complicating  infection. 

Every  injury  of  the  skull  is,  for  a  long  time,  a  source  of  potential  danger 
and  the  persistence  of  any  sign  or  symptom,  however  trivial,  is  to  be  looked 
upon  with  suspicion.  Further,  persistent,  cranial  fistula  means  the  definite 
existence  of  a  cranial  or  intracranial  foreign  body  of  some  sort,  which  must 
be  removed  if  possible,  because  of  the  danger,  if  not  the  certainty,  of  a  late 
abscess  of  the  brain,  or  meningeal  infection. 

Roberts  (Brit.  Med.  Jour.,  Oct.  2,  1915,  p.  498),  discussing  latent  grave 
injuries  with  apparently  minor  external  wounds,  states  that  "The  number  of 
patients  who  arrive  at  the  base  hospitals  with  bullet  wounds  of  the  scalp  is 
large,  but  as  their  injuries  are  apparently  superficial  and  their  symptoms  few 
or  none  they  are  frequently  transported  as  'sitting'  cases  and  on  arrival  there 
is  a  tendency  to  overlook  the  fact  that  a  fairly  high  percentage  have  definite 
lesions  of  the  skull,  or  of  the  skull  and  brain." 

Roberts'  analysis  of  these  lesions  found  at  operation  in  140  cases  of  this 
order  demonstrates  that  any  projectile  wound  of  the  scalp,  however  slight, 
should  be  subiect  to  early  exploration  to  determine  the  presence  or  absence  of 
a  fracture.     The  140  cases  included : 

Scalp  wounds  only 82 

Fracture  of  outer  table  only 19 

Fracture  of  inner  table  only 1 

Fracture  of  both  tables,  dura  uninjured   18 

Fracture  of  both  tables,  dura  lacerated  1 

Fracture  with  laceration  of  dura  and  brain 19 

The  excision  of  the  scalp  wound  down  to  and  including  the  pericranium,  as 
practised  by  Roberts  and  many  others  as  the  first  step  in  the  exploration  under 
novocain-adrenalin  or  general  anesthesia,  has  to  recommend  it  that : 

1.  The  diagnosis  of  fracture  is  usually  established  with  absolute  certainty. 

2.  If  no  bone  injury  is  found,  the  wound  is  sutured  without  drainage  and 
heals  by  primary  union  in  over  95  per  cent,  of  the  cases. 

3.  Time,  trouble  in  attendance,  and  expense  in  dressings  are  saved. 
Gushing  (Mil.  Surgeo'ii,  Jmie,  1916.  p.  601)  expresses  the  present  situation 

with  regard  to  the  treatment  of  cranial  injuries:  "There  is  no  unanimity  of 
opinion  as  to  what  should  be  the  routine  treatment  of  cranial  wounds  at  first 
line  hospitals.  Some,  owing  to  sorry  experience,  advocate  leaving  all  except 
the  minor  injuries  alone :  some  advise  immediate  trepanation  only  of  the 
tangential  wounds  in  which  the  dura  has  presumably  escaped  injury ;  but  by 


772  MODERN  MILITARY  SURGERY 

far  the  larger  number,  basing  their  views  on  the  experiences  of  earlier  wars, 
recommend  the  prompt  treatment  of  every  case  at  the  earliest  possible  moment. 
The  operation  usually  consists  of  enlarging  the  wound,  the  elevation  of  de- 
pressed fragments,  the  removal,  so  far  as  possible,  of  the  spicules  driven  into 
the  brain,  and  direct  drainage." 

Although  approximately  55  per  cent,  of  the  cases  of  cerebral  injury,  oper- 
ated on  within  a  few  hours  after  injury  under  the  necessarily  primitive  condi- 
tions of  the  usual  field  hospital,  die  from  meningo-encephalic  infection  and 
from  the  remote  fatalities  due  to  secondary  complications  months  afterward. 
Gushing  believes  that  "if  a  field  hospital  is  perfectly  equipped  in  personnel 
and  X-ray  apparatus,  and  a  thorough  neurologic  study  can  be  made,  imme- 
diate operation  may  be  desirable,"  but  under  any  less  ideal  conditions  he  is 
deeply  convinced  that  "the  likelihood  of  ultimate  perfect  recovery  is  seriously 
lessened,  if  preliminary  and  necessarily  incomplete  measures  are  there  under- 
taken."  He  further  states:  "I  believe  that  though  an  immediate  operation 
might  save  1  or  2  per  cent,  which  could  not  reach  a  suitable  base,  10  or  20  per 
cent,  could  be  spared  the  late  sequels  of  these  injuries  if  their  primary  opera- 
tion, even  with  a  delay  of  two  or  three  days,  could  be  done  under  ideal 
auspices." 

AYilms  recommends  immediate  removal  of  the  indriven  hair,  bone  and 
metal  fragments  and  the  crushed  and  softened  brain  in  tangential  shots,  on 
the  principle  that  early  operation  removes  the  foci  of  infection  before  the 
reactive  edema  becomes  well  established  and  lessens  both  the  traumatic  edema 
of  the  missile  and  operation  by  adequate  drainage.  Gray  states  that  septic 
wounds  of  the  scalp  and  skull  are  particularly  easy  to  deal  with  by  complete 
and  early  excision,  and  healing  takes  place  by  primary  union,  after  suture, 
unless  sepsis  has  obtained  a  firm  hold  in  the  lacerated  brain.  "Edema  and 
so-called  shock  are  no  bar  to  operative  success.  Indeed,  it  seems  likely  that 
both  pass  more  quickly  the  sooner  and  more  thoroughly  the  foreign  material 
is  removed,  pressure  and  edema  due  to  the  circulatory  obstruction  relieved 
and  adequate  drainage  established." 

Velter,  after  a  year's  experience  with  skull  wounds  seen  within  six  hours 
following  injury,  is  convinced  that  immediate  operation  in  these,  perhaps  more 
than  in  any  other  wounds,  is  essential  to  a  favorable  outcome,  for  there  is 
less  chance  of  infection,  less  need  of  drainage  and  more  opportunity  for 
primary  healing  of  the  operative  field.  He  believes  that  the  mechanical 
disinfection  of  a  wound  within  a  few  hours  of  its  incidence,  with  the  removal 
of  foreign  bodies  and  the  excision  of  dead,  disintegrated  tissue,  is  n^rly 
always  sufficient  to  ensure  secondary  reunion. 

Relative  to  the  time  of  operation,  the  degree  of  shock,  the  hospital  facili- 
ties and  the  type  of  surgical  skill  available  and  the  necessity  for  more  or  less 
prompt  transportation,  are  deciding  factors.  In  general,  the  safest  time  for 
operation  is  from  two  to  four  days  after  the  injury,  when  the  patient  has 
reached  a  permanent  and  well-equipped  base  hospital  where  X-ray  examina- 
tions can  be  made  and  the  scalp  adequately  prepared.  Sargent  and  Holmes 
state  that  delay  lessens  the  danger  of  infection  of  the  subarachnoid  space  by 
allowing  the  formation  of  adhesions,  and  further  lessens  the  danger  of  forma- 
tion of  hernia  cerebri.  Operative  reactive  inflammation,  added  to  the  traumatic 
edema  already  existing,  increases  the  tendency  of  the  brain  matter  to  protrude, 
hernia  cerebri,  of  course,  being  a  symptom  of  abnormal  intracranial  pressure. 
"Further,  the  lining  of  the  ventricular  cavity  tends  to  herniate,  first  into  the 
overlying  softened  brain  and  then  into  the  base  of  the  hernia  cerebri ;  ulti- 
mately it  may  rupture  and  discharge  cerebrospinal  fluid;"  ventricular  infec- 
tion folloM^ng  rapidly.  The  formation  of  a  cerebral  hernia  is  therefore  not 
only  dangerous  to  life,  but  to  the  function  of  the  protruded  brain  and  of  that 


1 


MODERN  MILITARY  SURGERY  773 

in  the  neighborhood  of  its  base,  the  finer  cortical  and  subcortical  structures 
being  unable  to  withstand  the  dragging  strain  placed  upon  them. 

"The  respective  dangers,  those  of  meningitis  and  of  hernia  formation, 
attendant  upon  early  operations,  and  those  of  infective  encephalitis  due  to 
retained,  infected  foreign  bodies,  and  of  ventricular  infection,  which  beset 
delay,  must  be  balanced  against  each  other,  experience  seeming  to  show  that 
the  dangers  of  early  operation  are  the  greater." 

As  serious  wounds  of  the  skull  have  been  overlooked  by  neglecting  the 
complete  clearing  of  the  scalp  of  hair,  this  is  the  first  step  in  the  local  prepara- 
tion for  operation.  This  is  best  and  most  quickly  done  by  clipping  the  hair  as 
close  as  possible  with  a  clipper  and  applying  a  depilatory  such  as  a  fresh 
mixture  of  2  parts  of  barium  sulphide,  5  parts  of  starch  and  1  part  of  orris 
root,  made  into  the  consistency  of  a  thin  paste  with  warm  water,  and  rubbed 
well  into  the  whole  scalp.  AVithin  ten  minutes  the  hair  can  be  entirely  scraped 
away  with  any  dull  instrument  and  the  excess  of  paste  removed  by  washing 
with  water,  the  razor  cuts  so  common  to  the  usual  shaving  preparation  being 
thereby  avoided. 

The  scalp  is  best  cleansed  with  alcohol  and  both  scalp  and  wound  thor- 
oughly painted  with  strong  tincture  of  iodine.  In  using  a  rubber  tourniquet 
about  the  head  to  control  bleeding,  pressure  upon  the  eyeballs  should  be 
avoided. 

The  first  step  of  the  exploration  is  the  complete  excision  of  the  contused 
and  septic  scalp  wound  down  to  and  including  the  pericranium.  If  no  evidence 
of  deeper  injury  is  found  either  locally  or  symptomatically,  the  wound  may 
be  sutured  at  once  and  usually  heals  by  primary  union.  If  the  skull  is  frac- 
tured, however,  it  is  seldom  necessary  to  trephine,  but  the  fragments  of  bone 
may  be  carefully  elevated  and  removed  luitil  room  is  created  for  the  insertion 
of  a  rongeur,  by  which  all  soiled  and  depressed  fragments  are  gently  gnawed 
away  until  the  gap  in  the  skull  is  rounded  off.  There  is  positive  danger  in 
allowing  free  buttons  or  fragments  of  bone  to  remain  over  the  dura,  for  later 
depression  and  epileptiform  symptoms  occur  from  such  sources.  Fissures 
should  be  rongeured  up,  especially  if  the  dura  beneath  them  is  torn.  Space 
for  these  more  extensive  manipulations  is  given  by  the  creation  and  reflection 
downward  of  a  broad  flap,  with  its  pedicle  downward,  in  the  middle  of  which 
is  placed  the  original  excised  scalp  wound,  which  is  later  closed  by  sliding 
a  layer  of  aponeurosis  over  the  defect. 

Numerous  observers  have  removed  metallic  foreign  bodies,  such  as  frag- 
ments of  bullets  and  shrapnel,  from  the  brain  with  a  minimum  of  trauma  by 
the  use  of  a  giant  magnet  and  at  times  under  direct  Roentgen-ray  control. 
Sargent  and  Holmes  use  soft  iron  rods,  12  to  18  cm.  long  and  1  to  1%  cm.  in 
diameter.  These  are  passed  along  the  track  of  the  missile  after  previously 
removing  the  fragments  of  bone  under  a  stream  of  hot  saline.  At  the  desired 
distance  the  nose  of  the  magnet  is  applied  to  the  end  of  the  rod  and  a  current 
having  a  pulling  strength  equivalent  to  several  pounds  applied,  this  being 
enough  to  attract  metal  fragments  an  inch  or  more  distant  from  the  point  of 
the  rod.  After  a  few  seconds,  during  which  the  click  of  an  attracted  foreign 
body  may  be  heard  or  felt,  the  apparatus  is  gently  withdrawn  and,  by  turning 
off  the  current,  the  attached  foreign  body  is  dropped  into  a  sterile  test  tube 
for  cultural  purposes. 

Where  thorough  cleansing  of  the  wound  has  been  possible  and  the  exist- 
ence of  sepsis  does  not  gainsay,  the  denuded  dura  or  brain  is  covered  and 
protected  by  scalp,  or  by  sliding  a  pericranio-aponeurotic  flap  after  the  in- 
genious manner  devised  by  Sargent  {Brit.  Jour,  of  Surg.,  Jan.  1,  1916),  the 
wound  being  drained  at  its  angles  by  rubber  tubes,  or  better  by  rubber  tissue 
wicks,  carried  down  to  but  not  into  the  bone  defect. 


774  MODERN  MILITARY  SURGERY 

Drainage  is  indicated  in  the  presence  of  pus,  of  infected  blood-clot,  of 
definitely  infected  but  inaccessible  foreign  bodies  and  where  there  is  free 
oozing  from  an  extensive  laceration  of  the  brain.  A  gauze  drain  is  never 
justifiable  in  wounds  of  the  brain  because  of  the  certainty  and  the  density  of 
the  adhesions  which  result.  Small,  fenestrated  rubber  tubing,  or  preferably 
rubber  tissue  wicks,  give  the  best  drainage,  while  the  latter  are  most  efficacious 
and  have  the  least  possible  efi'ect  as  a  foreign  body.  Sargent  and  Holmes  use 
glj^cerin  in  the  lumen  of  the  drainage  tubes  for  its  hygroscopic  effect,  its  in- 
hibiting action  upon  the  growth  of  pyogenic  cocci,  and  its  apparent  eft'ect  in 
emulsifying  disintegrated  brain  and  thus  aiding  its  escape.  The  drainage 
tubes  are  surrounded  by  gauze  soaked  in  glycerin  and  a  large  dressing  of 
gauze  and  wool  applied.  If  afterward  reactive  edema  tends  to  extrude  the 
tube,  lumbar  puncture  is  done. 

Perforating  wounds  of  the  skull  in  which  immediate  death  has  been 
escaped  usually  recover  without  operation,  although  in  some  of  the  more 
severe  cases  it  is  necessary  to  trephine  both  the  wound  of  entry  and  that  of 
exit,  where  wide  fissures  and  extensive  contusion  of  the  brain  may  exist. 

Fractures  of  the  base  of  the  skull  from  direct  projectile  injury  are  seldom 
operable  and  must  be  treated  expectantly  or,  upon  the  signs  of  beginning 
infection,  suboccipital  decompression  and  drainage  of  the  subarachnoid  space 
may  be  done,  according  to  the  method  of  Gushing. 

Lumbar  puncture  is  one  of  the  most  valuable  aids  in  the  diagnosis  and 
treatment  of  projectile  injuries  of  the  skull.  By  the  character  of  its  cellular, 
and  the  amount  of  its  albuminous  content,  the  spinal  fluid  gives  important 
information  as  to  the  extent  and  severity  of  the  injury,  and  by  its  immediate 
effect  in  reducing  the  intracranial  pressure,  the  operation  often  gives  prompt 
relief  to  the  severe  and  continuous  headache,  to  the  paralytic  phenomena, 
melancholia,  stupor  or  even  to  the  epileptiform  attacks  which  not  infrequently 
follow  simple  contusion  of  the  skull,  and  concussion,  without  focal  injury  of 
any  sort.  In  simple  concussion  and  in  most  non-penetrating  wounds  of  the 
skull  it  is  the  only  rational  treatment.  Fifteen  to  45  c.  c.  may  be  withdrawn 
daily,  as  indicated,  and  the  procedure,  even  repeated  in  this  way,  seems  harm- 
less unless  the  pressure  in  the  fluid  is  below  normal  to  start  with.  The  optic 
neuritis,  so  constantly  associated  with  all  these  forms  of  intracranial  pressure, 
is  benefited  in  proportion  with  other  symptomatic  improvement. 

In  air  concussion  the  intracranial  pressure  often  remains  high  for  days 
after  the  injury,  and  these  cases  appear  to  suffer  almost  none  of  the  conse- 
quences of  lumbar  puncture  seen  in  civil  life  when  done  for  diagnostic  purposes 
or  for  the  relief  of  diseased  conditions. 

Lumbar  puncture  is  also  of  particular  value  in  penetrating  wounds,  where 
it  lessens  the  tendency  to  the  formation  of  cerebral  hernia  and  aids  in  its 
control,  if  already  developed.  If  done  before  the  subarachnoid  space  about 
the  wound  has  become  closed  by  adhesions,  it  must  be  used  with  care  lest  it  be 
the  means  of  introducing  meningeal  infection,  which  may  also  result  from 
withdrawing  too  much  fluid,  thus  causing  the  brain  to  sink  back  from  the 
dura  and  tearing  the  adhesions.  ]\Iedullary  strangulation  in  the  foramen 
magnum  has  also  resulted  from  excessive  withdrawal  of  fluid.  The  diagnosis 
of  rupture  into,  and  of  infection  of,  the  lateral  ventricle  also  may  be  aided  by 
examination  of  the  spinal  fluid. 

"Where  lumbar  puncture  fails  to  relieve  increasing  pressure  symptoms,  a 
contra-lateral  subtemporal  decompression  may  be  indicated. 

As  a  further  aid,  the  use  of  urotropin  in  doses  of  1.0  to  2.0  grams  every 
three  or  four  hours  is  indicated  in  every  projectile  injury  of  the  skull  with 
accompanying  fracture,   and  is  to  be   continued  until  danger  of  immediate 


2I0DERX  MILITARY  SURGERY  775 

infection  is  past.    Bromides  in  full  doses  are  necessarj-  for  months  after  every 
cerebral  injury. 

Helmets.  The  degree  of  prevention  of  cranio-ocular  injuries  which  may  be 
effected  by  metal  helmets  of  the  type  adopted  by  the  French,  later  modified 
by  the  Belgians,  English  and  Germans,  still  remains  to  be  determined.  They 
seem  to  be  highly  effectual  against  schrapnel,  spent  projectiles  and  the  multi- 
tude of  fine  secondary  missiles  which  so  frequently  and  disastrously  involve 
the  eyes ;  and  the  overhanging  brim  protects  both  the  eyes  and  the  occipital 
region.  The  frequency  of  minor  wounds  and  contusions  still  is  increased,  but 
helmets  apparently  reduce  the  proportion  of  severe  or  fatal  cases. 

FACE  INJURIES 

It  is  remarkable  that  the  eyes,  whose  combined  surface  is  only  about  ^75 
of  the  surface  of  the  body,  should  be  involved  in  approximately  8  per  cent,  of 
all  injuries,  but  the  explanation  lies  in  the  constant  exposure  of  the  head,  and 
especially  the  eyes,  in  trench  warfare ;  in  the  fact  that  the  eyes  are  so  fre- 
quently injured  by  fine  particles  which  would  have  no  deleterious  effects 
elsewhere  in  the  body ;  and  in  the  great  frequency  of  symptomatic  involve- 
ment as  a  consequence  of  remote  lesions. 

Naturally,  the  less  imperative  measures,  such  as  the  routine  radiographic 
examination,  the  more  complicated  cases  of  intraocular  foreign  bodies  and 
extensive  plastic  operations  on  the  orbit  and  lids,  are  preferably  done  in  the 
reserve  or  civil  hospitals,  but  provision  for  the  adequate  first-aid  treatment  for 
these  and  for  all  eye  wounds  soon  after  injury  and  while  en  route  to  the  rear 
is  a  matter  of  such  consequence  in  preserving  vision  and  in  preventing  infec- 
tion, that  a  knowledge  of  its  essentials  should  be  spread  among  civilian  sur- 
geons suddenly  called  to  active  military  duty,  and  among  professional  military 
surgeons  as  well,  by  means  of  special  instructions.  A  comprehensive  summary 
of  such  instructions  follows:     (Mills) 

First  aid  in  battle  wounds  of  the  eyes. 

1.  Before  cleansing  or  manipulating  a  recently  injured,  sensitive  eye, 
lightly  anesthetize  it  with  from  2  to  3  drops  of  4  per  cent,  solution  of  cocaine, 
instilled  at  3  minute  intervals. 

2.  Cleanse  the  skin  of  the  lids  and  the  adjacent  field  by  gently  washing 
with  soap  and  water,  followed  by  benzene  (benzol). 

3.  Cleanse  the  conjunctival  sac  of  loose  foreign  material  by  free  irriga- 
tion with  warm  3  per  cent,  solution  of  boric  acid,  warm  normal  saline  or 
warm  1/10,000  bichloride  or  oxycyanate  of  mercury,  whichever  may  be  avail- 

.able,  not  forgetting  that  strong  antiseptics  may  seriously  damage  the  cornea. 

4.  Where  foreign  bodies  are  deeply  imbedded  in  the  cornea  and  where  the 
whole  cornea  and  conjunctiva  is  tattooed  with  indriven  mud.  fragments  of 
stone  or  metal,  the  dangers  of  corneal  perforation  and  infection  are  so  great 
that  such  cases  should  be  hurried  to  the  nearest  specialist  center. 

5.  A  wound  of  the  eyeball,  the  gray-white  change  of  a  traumatic  cataract 
and  effused  blood  in  the  anterior  chamber,  usually  mean  perforation  of  the 
eye  by  a  foreign  body.  These  cases  demand  the  earliest  possible  specialized 
care  and  should  be  given  precedence  of  way  to  the  rear. 

The  chances  of  infection  of  the  globe  through  the  open  wound  are  so 
greatly  lessened  by  promptly  covering  the  wound  with  a  flap  of  conjunctiva 
that  more  eyes  can  be  saved  and  more  practical  vision  retained  in  such  eyes 
by  this  than  by  any  other  single  procedure.  AVith  corneal  wounds  a  sufficient 
amount  of  adjacent  conjunctiva  is  undermined  and  drawn  down  and  held  in 
place  over  the  opening  by  simple  eonjimctival  sutures  of  fine  silk  at  each  angle. 
If  the  laceration  is  considerable,  but  there  are  possibilities  that  some  vision 


776 


MODERN  MILITARY  SURGERY 


may  be  retained,  the  entire  cornea  may  be  thus  covered  and  protected  by  under- 
mining the  conjunctiva  throughout  the  whole  circumference  of  the  cornea  and 
uniting  it  over  the  front  of  the  globe. 

6.  Both  eyes  should  be  put  at  rest  by  full  dilation  of  the  pupils  with  1 
per  cent,  atropine,  a  matter  of  much  importance  during  rough  transportation, 
and,  unless  contraindicated,  both  eyes  should  be  lightly  bandaged,  using 
gauze,  cotton  and  bandage  material  from  within  outwards.  In  a  few  cases  if 
tension  of  the  eye,  determined  by  palpating  the  globe  between  the  index  fin- 


Shell  Wound  of  the  Lower  Jaw. 


■"nt: 


Actual  Size  of  Fragment  of  High-Explosive  Shell  Eemoved  from  Lower  Jaw  of  Previous 

Case. 


gers,  is  high,  and  in  this  condition  instillations  of  a  1  per  cent,  solution  of 
eserine  are  indicated,  instead  of  atropine,  until  the  pupil  is  very  small. 

7.  Eyes  wdiich  are  suppurating  from  any  cause  should  not  be  bandaged, 
but  are  to  be  washed  out  freely  and  frequently.  Extension  of  the  infection  to 
the  sound  eye  and  to  the  eyes  of  others  is  to  be  guarded  against. 

8.  Unless  an  eye  is  completely  shattered,  too  early  enucleation  is  not  to 
be  counseled.  Sympathetic  inflammation  of  the  sound  eye  is  almost  unknown 
inside  of  two  weeks  after  injury,  and  many  eyes  are  blinded  for  the  time 


MODERN  MILITARY  SURGERY 


777 


A. 


B.  C. 

Operative  Stages  Shown  in  a  Series  of  Three  Photographs  of  the  Same  Case.    Shrapnel 

Wound  of  the  Face  and  Jaw. 


778  MODERN  MILITARY  SURGERY 

being  by  intraocular  hemorrhage  which  may  clear  in  a  few  weeks  or  months 
and  leave  more  or  less  useful  vision.  The  decision  in  this  matter  of  such 
importance  is  best  made  at  the  specialist  center. 

9.  Inflamed  and  tender  eyes  with  failing  vision  or  without  vision  are  best 
enucleated  at  once,  because  of  the  danger  of  sympathetic  inflammation  of  the 
sound  eye.  The  conjunctiva  and  the  ocular  muscles  are  spared  as  much  as 
possible  in  order  to  form  the  best  possible  socket  for  an  artificial  eye. 

10.  Eyes  that  have  been  shattered  are  to  be  enucleated  at  once,  with  par- 
ticular care  to  remove  all  fragments  of  bone,  which  are  so  commonly  driven 
deeper  into  the  orbital  fat.  By  early  operation,  excessive  cicatricial  contrac- 
tion is  avoided  and  a  far  better  bed  formed  for  an  artificial  eye. 

11.  Fragments  of  missiles  lodged  in  the  orbital  tissues  are  harmless,  espe- 
cially if  they  produce  no  evidence  of  irritation. 

12.  Defects  in  the  lids  should  be  repaired  at  once,  lest  cicatricial  contrac- 
tion make  a  good  operative  result  difficult  or  impossible  to  obtain. 

13.  Wounds  of  the  eyes  and  orbit  are  no  exceptions  to  the  routine  employ- 
ment of  antitetanic  serum  in  military  wounds. 

14.  The  routine  use  of  narcotics  in  injuries  of  the  eyes  is  to  be  deplored, 
in  view  of  the  possibility  of  habituation.  Small  doses  of  paregoric  or  tincture 
of  opium  are  usually  sufficient. 

15.  The  inclusion  in  the  medical  equipment  of  a  focusing  lens,  a  self- 
retaining  lid  retractor,  an  instrument  for  removing  foreign  bodies  from  the 
cornea,  and  of  atropine,  eserine  and  cocaine  in  the  form  of  salts  or  solutions  is 
essential  for  the  adequate  care  of  battle  injuries  of  the  eyes. 

Face  and  jaws.  Some  of  the  most  mutilating  and  horrible  results  of 
modern  warfare  are  seen  in  battle  wounds  of  the  face  and  jaws.  Such  wounds 
range  in  severity  from  simple  perforations  of  the  cheek  to  destructions  of 
from  one-half  to  two-thirds  of  the  entire  face.  Great  difficulties  often  arise 
due  to  the  fact  that  the  man  must  breathe  and  receive  nourishment  through 
some  portion  of  the  wound,  and  so  an  injury  of  these  parts  not  infected  is 
never  seen. 

The  primary  treatment  of  shell  wounds  of  the  face  and  jaws  resolves  itself 
into  the  control  of  hemorrhage,  removal  of  foreign  bodies  and  shattered  small 
bones,  and  application  of  Dakin's  solution  by  the  irrigation  of  the  dressing 
method.  After  the  infection  has  cleared  and  there  are  healthy  granulations 
formed,  it  is  time  to  do  a  plastic  operation  for  the  proper  closure  of  the 
wound.  This  type  of  reconstructive  or  plastic  surgery  is  one  of  the  most 
difficult  in  military  surgery,  and  it  is  for  this  reason  that  plastic  operations 
upon  the  face  and  jaws  are  referred  to  men  having  a  special  adaptability  for 
such  work. 

GUNSHOT  WOUNDS  OF  THE  CHEST 

One  of  the  most  striking  features  of  a  modern  military  hospital  is  the  large 
tfttmber  of  penetrating  gunshot  wounds  of  the  chest  admitted  with  compara- 
tively trivial  sj^mptoms.  The  immediate  results  following  such  injuries  are 
often  marked  and  severe,  but  those  patients  who  survive  and  are  sent  to  a 
base  hospital  are  often  surprisingly  well  when  first  admitted.  The  experience 
of  military  surgeons  in  the  present  campaign  serves  to  confirm  the  observa- 
tions made  in  the  South  African  War,  viz.,  that  the  modern  high  velocity, 
hard-jacketed  rifle  bullet  can  pass  through  almost  any  part  of  the  lung,  and 
sometimes  even  through  the  heart,  without  death  of  the  patient  resulting. 

It  is  impossible  to  calculate  with  any  degree  of  accuracy  how  many  cases 
of  gunshot  wounds  of  the  chest  die  on  the  field  of  battle  from  injury  to  the 
heart  or  large  vessels,  but  it  would  seem  that  even  extensive  wounds  of  the 


MODERN  MILITARY  SURGERY  779 

lung  and  chest  wall  may  be  recovered  from.  The  actual  site  of  penetration 
of  the  chest  is  undoubtedly  of  importance,  as  many  with  injuries  to  the  root 
of  the  lungs  and  large  vessels,  die  soon  after  injury ;  but  in  those  that  recover 
sufficiently  to  be  removed  to  a  base  hospital,  injuries  are  met  with  in  every 
conceivable  portion  of  the  chest,  and  recovery  is  little  affected  by  the  site  of 
the  wound. 

A  very  noticeable  feature  in  cases  of  gunshot  wounds  of  the  chest  is  the 
rapid  recovery  where  there  is  no  destruction  of  the  chest  wall,  compared  with 
the  high  mortality  in  cases  with  an  open  wound  on  arrival  at  the  base.  Cases 
where  a  wound  in  the  chest  opens  into  the  pleural  cavity,  with  communication 
between  that  cavity  and  the  outer  air,  are  almost  uniformly  fatal. 

Captain  J.  L.  Menzies  at  Alexandria  has  recently  made  a  study  of  75  cases 
of  injuries  to  the  chest  and  a  summary  of  his  results  follow : 

The  primary  symptoms,  in  the  order  of  frequency,  are  pain,  shock,  dyspnea 
and  hemoptysis,  all  of  which  occur  at  the  time  of  injury,  or  soon  after. 

Pain  is  rarely  very  severe  and  calls  for  little  comment.  Shock  may  be 
severe,  at  times  resulting  in  loss  of  consciousness,  but  a  few  of  the  men  are 
able  to  walk  after  the  injury.  Dyspnea  is  almost  always  present  at  the  time 
of  the  injury,  and  is  generally  characteristic.  Among  75  cases,  only  12  gave 
no  history  of  dyspnea.  In  48  cases  there  was  hemoptysis,  40  immediate  and  8 
delayed.  The  temperature  is  said  to  be  elevated  in  all  cases  after  chest 
injury.  After  admission  to  the  base  hospital,  the  predominant  symptoms  are 
dyspnea  and  pyrexia. 

Of  the  75  cases  admitted  to  the  hospital,  56  were  wounded  by  rifle  bullets 
and  19  by  shrapnel  or  bombs.  The  latter  wounds  were  more  severe,  as  a  rule. 
A  large  proportion  of  projectiles  were  retained  in  the  chest.  This  was  the 
case  on  admission  in  35  instances — 26  bullets  and  9  pieces  of  shrapnel :  4  rifle 
and  4  shrapnel  bullets  were  extracted  from  the  chest  wall  or  pleural  cavity, 
and  27  patients  were  discharged  from  hospital  with  the  projectile  still  retained 
and  apparently  causing  no  symptoms.  The  presence  or  absence  of  the  missile 
seems  to  make  little  difference  to  recovery. 

Treatment.  All  cases  of  perforating  wounds  of  the  chest  must  be  carefully 
watched  from  the  time  of  injury.  The  immediate  symptoms  generally  improve 
when  the  patient  is  kept  quiet.  Hemoptysis  ceases  spontaneously  in  nearly 
all  cases.  At  the  time  of  injury,  morphine  may  be  given  and  any  bleeding 
from  intercostal  arteries  should  be  arrested ;  but,  as  a  rule,  no  further  treat- 
ment is  necessary  beyond  keeping  the  patient  quiet.  On  admission  to  hospital, 
when  there  is  no  effusion  into  the  pleural  cavity,  no  special  treatment  is 
necessary,  and  recovery  is  rapid. 

When  effusion  is  present,  the  chest  should  be  explored  at  an  early  date 
and  the  fluid  examined  bacteriologically.  When  the  fluid  is  found  to  be 
sterile  it  may  or  may  not  be  aspirated :  In  cases  where  the  effusion  is  large, 
with  marked  dyspnea  and  much  displacement  of  the  mediastinum,  it  is  always 
advisable  to  aspirate  the  fluid ;  when  the  effusion  is  not  large,  it  may  be 
aspirated  or  left  alone. 

When  definite  pus  is  present,  the  pleural  cavity  should  be  drained  at  the 
earliest  possible  time  by  the  resection  of  ribs.  In  old  pleural  cavities  follow- 
ing drainage,  irrigation  with  Dakin's  solution  is  indicated.  The  majority  of 
cases  occasion  no  anxiety  from  the  time  of  admission;  their  recovery  is  unin- 
terrupted, although  signs  of  fluid  may  be  present  for  a  long  time  after  the 
patients  are  apparently  well.  It  is  beneflcial  to  get  them  up  early,  even 
before  the  temperature  is  quite  normal,  and  to  practice  gentle  exercises  and 
breathing  exercises. 


780  MODERN  MILITARY  SURGERY 

WOUNDS  OF  THE  ABDOMEN 

In  the  early  months  of  the  war,  penetrating  wounds  of  the  abdomen  were 
usually  treated  on  an  expectant  plan,  but  it  was  soon  demonstrated  that  most 
penetrating  woimds  of  the  abdomen  should  be  operated  upon  early.  ^Yebb 
and  Milligan  give  an  interesting  description  of  cases  seen  during  the  first 
year  of  the  war,  of  which  a  summary-  follows : 

"1.     "We  believe  it  advisable  not  to  operate  at  sight  and  on  principle  on 

every  case  of  suspected  penetrating  wound  of  the  abdomen,  but  to  make  as 

definite  a  diagnosis  as  is  possible  before  deciding  whether  to  operate  or  not. 

"2.     We  think  it  advisable  to  wait  a  certain  time  after  the  case  has  been 

admitted,  for  the  following  reasons : 

"a.     To  combat  shock. 

"b.     To  distinguish  between  moribund  cases  and  those  that  rally 

with  'anti-shock'  measures, 
"c.     To   endeavor  to   distinguish   cases   requiring   operation  from 
those  likely  to  recover  without  operation, — i.  e.,  that  group 
of  cases  which  rally  with  anti-shock  measures. 
"3.     It  is  essential  to  operate  in  every  case  that  rallies  well,  where,  after 
due  consideration,  we  believe  a  hollow  viscus  to  have  been  wounded,  or  where 
we  have  reason  to  suppose  that  progressive  hemorrhage  is  taking  place. 

"4.  It  is  useless  to  operate  in  bad  cases  that  do  not  respond  to  preopera- 
tive shock  therapeusis. 

"5.  We  do  not  think  it  advisable  at  present  to  operate  in  a  casualty 
clearing  station  on  cases  in  which  we  have  reason  to  believe  solid  organs  alone 
are  injured,  and  in  which  there  are  no  signs  of  continued  hemorrhage. 

"6.     During  operation  it  is  of  the  utmost  importance  to  follow  a  rigid 
routine  method  of  examination  of  the  abdominal  contents,  keeping  in  one's 
mind  as  far  as  possible  the  track  of  the  wound. 
"Minor  points  are : 

''a.     To  make  a  complete  and  detailed  estimate  of  the  number  and 
character  of  all  the  lesions  wrought  by  the  projectile  before 
attempting  any  remedial  measures, 
"b.     The  performance  of  one  resection  of  gut  where  possible  rather 

than  multiple  sutures, 
"c.     Not  to  place  sutures  in  devitalized  tissues. 
"d.     A  careful  search  for  the  missile. 

"e.     Completeness  of  operation,  especially  thorough  closure  of  the 
inevitably  large  laparotomy  wound.    AVe  suture  the  abdom- 
inal wall  in  layers. 
"7.     Post-operative  shock  is  never  negligible  and  in  most  cases  is  almost 
certain  to  be  the  most  dangerous  complication  to  be  feared  after  the  case  has 
left  the  table." 

The  expectant  treatment  of  abdominal  injuries  was  the  method  of  choice 
in  the  armies  of  all  the  combatants  at  the  beginning  of  the  war.  Gradually  on 
every  side  the  operative  has  replaced  the  older  method.  Although  it  is  very 
difficult  to  compare  the  two  methods,  some  interest  attaches  to  the  figures 
obtained  in  the  two  periods  respectively.  The  figures  in  the  preoperative 
period  have  to  be  taken  from  the  admission  and  discharge  books  of  the  field 
ambulances  and  casualty  clearing  stations,  as  no  special  books  were  kept; 
consequently  the  figures  could  only  be  computed.  In  the  second  period,  special 
books  were  used  and  the  figures  may  be  taken  as  approximately  correct. 

Cuthbert  "Wallace  reports  that  into  nine  field  ambulances  over  a  period  of 
six  months,  there  were  admitted  1,098  abdominal  wounds,  with  .333  deaths, — 
a  mortality  of  30  per  cent.     In  the  six  casualty  clearing  stations  during  the 


MODERN  MILITARY  SURGERY  781 

same  period  there  were  admitted  131  eases  of  perforated  abdominal  wounds, 
with  73  deaths.  From  these  figures  it  appears  that  the  total  mortality  in  the 
field  ambulances  and  clearing  stations  was  about  70  per  cent.  There  were 
also  the  deaths  at  the  base  in  France  to  be  added,  and  the  preoperative  period 
to  which  we  now  allude.  Many  such  deaths  occurred  which  would,  as  far  as 
can  be  judged,  bring  the  mortality  up  to  about  80  per  cent.  As  showing  the 
difficulty  of  arriving  at  accurate  figures,  it  was  stated  by  some  that  80  per  cent, 
of  abdominal  wounds  recovered. 

General  incidence  of  wounds.  The  charts  were  made  by  plotting  the  en- 
trance wounds  on  the  front  and  back  of  the  body  respectively.  The  wounds 
of  the  back  form  a  substantial  proportion  of  the  whole.  There  is  a  tendency 
for  the  wounds  to  collect  towards  the  sides,  especially  on  the  back  of  the  body. 

The  comparative  absence  of  mid-line  wounds  is  also  seen,  which  represents 
the  wounds  in  cases  too  bad  for  operation  when  they  reach  a  casualty  clearing 
station.  This  distribution  is  brought  about  by  the  presence  in  the  mid-line  of 
the  spine  and  great  vessels.  Men  shot  in  these  situations  die  on  the  battle- 
field. The  collection  of  wounds  towards  the  sides  of  the  body  may  also  be 
caused  by  the  fact  that  a  man's  front  and  back  are  more  or  less  protected  in 
the  trench,  while  the  sides  of  the  body  are  opened  to  enfilade.  Many  of  the 
wounds  of  the  back,  especially  those  of  the  buttock  and  thigh,  are  due  to 
bombs  and  rifle  grenades,  a  man  instinctively  turning  his  back  to  such  a 
projectile  in  attempting  to  get  away  from  it. 

The  posterior  wounds  show  a  larger  proportion  of  deaths  than  the  anterior. 
In  nearly  every  case  there  was  much  blood  in  the  abdomen,  and  in  13  cases 
the  note  was  made  that  death  was  due  to  hemorrhage.  In  only  5  cases  was 
shock  noted  as  the  cause  of  death:  (1)  Perforation  of  ileum  with  a  shattered 
OS  ilium;  (2)  Multiple  wounds  of  small  gut;  no  blood  in  belly;  (3)  Shock;  no 
other  details;  (4)  Wound  of  ileum  and  sigmoid;  peritonitis  and  shock;  (5) 
Wound  of  rectum  and  small  gut.  In  one  case  retroperitoneal  sepsis  was  noted 
as  the  cause  of  death.  In  only  three  instances  was  peritonitis  deemed  the 
cause  of  death.  The  number  of  times  the  small  gut  was  injured  is  the  salient 
feature  in  the  series,  and  perhaps  another  interesting  point  is  the  fact  that 
the  stomach  figures  five  times.  Wounds  of  the  solid  organs  were  responsible 
for  death  in  twelve  instances. 

In  the  chart  are  a  good  many  buttock  wounds.  From  experience  gained  in 
operating  upon  such  cases,  we  must  regard  lesions  of  the  pelvic  vessels  as  a 
frequent  cause  of  death. 

Some  curious  instances  of  side-to-side  wounds  may  be  of  interest:  (1)  A 
wound  of  the  upper  pole  of  the  left  kidney  and  lower  pole  of  the  right,  wound 
of  ascending  colon,  paraplegia;  fatal.  (2)  Wound  of  the  right  kidney  and 
spleen;  vertebra  penetrated;  no  paraplegia;  fatal  from  splenic  hemorrhage. 
(3)  Spleen  torn  to  its  anterior  edge,  left  kidney  perforated  through  its  center, 
upper  pole  of  right  kidney  destroyed;  fatal,  (bullet).  (4)  Wound  of  the  left 
kidney  and  the  posterior  surface  of  the  ascending  colon ;  fatal. 

Cases  recovering  without  operation.  The  accompanying  figure  was  ob- 
tained by  plotting  the  entrance  wound,  the  track  of  the  bullet  when  known  in 
cases  that  recovered  without  operation.  Most  of  these  wounds  lie  within  the 
liver  area.  The  chart  also  shows  wounds  in  various  other  parts  of  the  abdo- 
men, and  the  explanation  of  their  recovery  is  most  probably  due  to  the  fact 
that  the  hollow  viscera  had  escaped,  although  the  abdomen  had  been  penetrated. 

Epigastric  wounds  are  usually  accounted  as  stomach  wounds  and  recovery 
is  often  recorded  as  an  instance  of  spontaneous  healing.  Operation  has  proved 
that  in  some  cases  the  projectile  leaves  the  stomach  and  perforates  the  gastro- 
hepatic  omentum.     Naturally,  wounds  in  this  region  will  often  involve  both 


782  MODERN  MILITARY  SURGERY 

surfaces  of  the  stomach.  Epigastric  wounds  have  not  maintained  their  repu- 
tation as  favorable  lesions. 

As  in  civil  life,  one  meets  with  a  fair  number  of  abdominal  injuries  caused 
by  horse  kicks.  Others  are  caused  by  falling-in  of  dug-outs,  by  burial  of  men 
by  shell  explosions,  and  by  blows  of  fragments  of  wood  which  are  hurled  about. 
They  present  nothing  out  of  the  common,  and  the  injuries  seen  are  the  same  as 
some  in  civil  life. 

Comparative  frequency  of  wounds  in  different  viscera.  The  following 
table,  quoted  by  Wallace,  gives  some  idea  of  the  relative  frequency  with  which 
different  organs  in  the  abdomen  are  wounded.  The  total  number  of  cases  from 
which  the  table  was  made  was  965. 

Viscus  No.  of  wounds  Viscus  No.  of  wounds 

Stomach   82  Kidney    73 

Small  gut 363  Bladder 45 

Colon 252  Pancreas  • 5 

Liver 163  Spleen 54 

General  lines  of  treatment.  "Accumulative  experience  shows  the  wisdom 
of  operation  as  a  rule.  It  is  now  mainly  a  question  of  excluding  a  few  cases 
on  which  it  is  best  not  to  operate.  It  can  be  frankly  admitted  that  this  line  of 
treatment  involves  operating  upon  some  patients  who  would  have  got  well 
without.  It  also  involves  operating  on  a  certain  number  of  cases  where  there 
is  bleeding  without  visceral  injury,  which  also  might  have  recovered  without. 
On  the  whole,  it  may  be  said  that  the  policy  of  'look  and  see'  is  better  than 
one  of  'wait  and  see.' 

"It  may  be  useful  to  enumerate  those  cases  which  were  best  left  alone. 

"1.  Cases  in  very  hod  condition.  There  are,  of  course,  many  cases  which 
no  surgeon  would  feel  himself  justified  in  operating  on ;  but  there  are  many 
border-line  cases  which  some  surgeons  would  leave  and  others  would  feel 
constrained  to  give  the  chances  of  operation  to.  Here  the  personal  equation 
comes  in,  and  whether  he  operates  or  not  must  be  left  to  the  surgeon  to  decide. 
Here  again  the  pulse  will  be  a  valuable  guide.  The  bolder  surgeon  will  get 
the  worse  operative  mortalities. 

"2.  Cases  shot  high  up  in  the  abdomen  in  the  liver  area.  Such  cases  on  the 
whole  do  very  well  if  left  alone,  so  long  as  there  are  no  symptoms  of  hemor- 
rhage,— in  fact,  hemorrhage  is  the  only  reason  for  operating  upon  liver  cases 
or  those  involving  any  solid  organ.  It  is,  of  course,  true  that  a  certain  number 
of  cases  succumb  to  sepsis  at  the  base,  but  their  number  is  not  sufficiently 
great  to  warrant  early  interference  on  that  account. 

"3.  High  ahdomino-thoracic  wounds  on  the  left  side.  The  type  of  wound 
more  especially  referred  to  is  that  which  enters  somewhere  near  the  mid-line 
behind  and  emerges  somewhere  towards  the  posterior  part  of  the  axilla  about 
the  level  of  the  sixth  to  the  eighth  rib.  These  wounds  are  sometimes  accom- 
panied by  symptoms  suggesting  stomach  involvement,  but  on  the  whole  do 
not  seem  to  do  so  badly ;  and  operative  interference  does  not  afford  very  much 
help,  as  wounds  high  up  in  the  cardia  or  near  the  esophagus  are  almost  im- 
possible to  close,  or,  if  they  can  be  reached,  involve  such  disturbances  as  are 
likely  to  lead  to  a  fatal  result. 

"4.  Cases  arriving  late.  I  am  inclined  to  put  down  twenty-four  hours  as 
a  usual  limit  within  which  a  primary  operation  is  likely  to  be  successful ; 
hemorrhage  by  this  time  has  ceased,  and  operation  is  only  likely  to  spread 
infection  if  the  bowel  has  been  perforated,  and  to  hasten  the  end.  There  are 
some  cases  in  which  operation  may  be  thought  advisable,  namely  those  with 


MODERx\  MILITARY  SURGERY 


783 


Lacerated  Bullet  Wound  of  Spleex. 


%  f J 


.-^ 


^ 

'r*-^-^- 


>l^^ 


0 


Bullet  Wouxds  of  Small  Ixtestixe, 


784  MODERN  MILITARY  SURGERY 

a  fair  pulse,  but  with  vomiting ;  the  operation  being  performed  with  the  idea 
of  getting  over  the  obstruction  by  short-circuiting  or  an  enterostomy.  Opera- 
tions of  this  class  have  nearly  all  been  fatal." 

GUNSHOT  FRACTURES 

Due  to  the  unusually  high  velocity  of  the  missiles  used  in  the  present  war, 
fractures  are  very  common.  Besides,  these  fractures  are  nearly  all  com- 
minuted and  are  all  infected.  These  facts  constitute  a  serious  problem  to 
solve  on  the  battlefield. 

Compound  fractures  are  practically  always  accompanied  by  other  wounds 
in  other  portions  of  the  body,  and  often  by  an  intense  degree  of  shock. 
Particles  of  clothing  are  usually  carried  into  the  wound  by  the  bullet  or  shell 
fragment.  The  great  difference  between  civil  and  military  surgery  of  frac- 
tures is  in  the  accompanying  comminution  and  great  destruction  of  the  soft 
parts  in  the  latter  cases. 

The  treatment  of  fractures  resolves  itself  into : 

1.  Treatment  of  shock. 

2.  Treatment  of  infection. 

3.  Removal  of  foreign  bodies  and  entirely  loose  splinters  of  bone. 

4.  Immobilization  of  the  limb. 

5.  Extension  of  the  broken  bone,  sufficient  to  secure  correct  alignment 
and  full  length. 

6.  Semiflexion  of  the  joints  above  and  below  the  broken  bone,  to  relieve 
the  tension  of  the  flexors  and  to  place  the  limb  in  a  position  of  physiological 
rest. 

The  injured  portion  of  the  limb  must  be  kept  at  rest.  The  difficulty  arises 
in  carrying  out  immobilization  and  extension  without  hindering  the  treatment 
of  the  wound.  Dressing  without  movement  is  an  important  point  in  the  treat- 
ment of  gunshot  fractures,  especially  in  the  leg,  because  the  weight  of  the 
lower  limb  causes  great  displacement  to  occur  when  it  is  raised  for  dressing. 

Extension  methods.  The  use  of  Buck's  extension  b}^  means  of  adhesive 
strips  is  usually  not  possible  because  of  the  presence  of  the  wound.  "When  it 
can  be  used,  however,  it  is  an  excellent  means  of  extension. 

For  the  leg,  metal  skeleton  splints  have  proved  the  most  useful ;  the  Thomas 
and  Page  splints  at  present  being  most  used.  All  alike  aim  at  a  bearing  on  the 
tuber  ischii  and  the  pelvis,  and  a  steadying  of  the  fracture  by  extension. 
They  have  been  of  great  service  and  are  far  the  best  form  of  apparatus  for  use 
near  the  front,  and  for  conveyance  in  ambulances  and  trains.  The  Balkan 
suspension  splint  is  also  a  good  form  to  use,  especially  in  the  later  treatment, 
as  the  patient  can  help  himself  to  a  great  extent. 

The  treatment  of  the  arm  is  comparatively  much  simpler,  because  the 
weight  of  the  member  can  be  used  as  a  means  of  extension  with  the  man  in  an 
upright  position.  With  the  added  weight  of  a  plaster  cast,  a  Kramer  woven- 
wire  splint,  or  the  much  superior  open  heavy  wire  splint  of  Thomas,  Eiselsberg 
or  Englemann,  the  last  three  allowing  free  access  to  the  wound,  there  develops 
traction  from  the  gravity  pull  alone. 

There  is  a  great  temptation  to  use  plates,  screws  and  wire,  but  it  is  doubtful 
whether  this  is  good  practice  in  compound  fractures.  It  will  take  a  good  deal 
of  evidence  to  show  that  internal  splinting  is  to  be  accepted  as  a  principle  in 
the  treatment  of  gunshot  injuries. 


MODERN  MILITARY  SURGERY 


785 


H 

'i^H^^^^SB 

■■■ 

/ 

!■■■ 

^^^i| 

'^^ 

1 

«Kl-*- 

HlllUHHllHHHrilHll^Hl 

^^ 

Method  of  Treating  Compound  Fracture  of  the  Leg  by  an  Interrupted  Plaster  Cast. 


A  B 

The  Hinged  Cradle  Splint. 
(a)  Raised  on  the  strut,  as  for  dressing,  (b)  Horizontal  position. 


Blake's  Splint  Applied  to  a  Compound  Fracture  of  the  Middle  Third  of  the  Femur. 

The  splint  is  made  entirely  of  metal  and  is  practically  in  two  pieces.  It  is  about  eleven 
inches  wide  at  the  top  and  four  inches  between  the  bars  at  the  bottom,  easily  adjusted  to  a 
large  or  a  small  thigh.  The  patient  being  placed  in  bed,  after  applying  the  first  careful  dress- 
ing, the  splint  is  suspended  as  shown,  and  a  ten-pound  traction  applied.  The  splint  is  comfort- 
able and  allows  dressing  as  required. 


786  MODERN  MILITARY  SURGERY 

'  NERVE  INJURIES 

There  is  a  relatively  greater  proportion  of  nerve  injuries  in  modern  war- 
fare, and  the  subject  has  become  one  of  great  importance  in  diagnosis  and 
treatment.  The  reason  for  a  greater  incidence  is  probably  in  the  larger  num- 
ber of  gunshot  injuries  due  to  high  velocity  bullets  that  cause  complete  rupture 
of  the  nerve  trunk.  When  the  nerve  is  traversed  in  an  acute  angle  to  its  long 
axis  there  is  a  correspondingly  greater  involvement.  Particles  from  shells  or 
bullets  or  secondary  missiles  may  become  imbedded  in  the  substance  of  the 
nerve,  causing,  besides  the  palsy,  unbearable  neuritic  pains.  A  scar  develop- 
ing about  a  nerve  may  cause  a  secondary  paralysis,  the  nerve  having  escaped 
the  bullet. 

Diagnosis.  The  diagnosis  of  the  actual  injury  which  a  nerve  has  sustained 
is  very  difficult,  and  in  a  large  number  of  cases  impossible,  especially  in  the 
differential  diagnosis  of  contusion,  partial  severing  and  complete  break  in 
continuity  of  a  nerve  trunk,  for  a  reaction  of  degeneration  is  apt  to  be  present 
in  all  three  conditions.  However,  there  are  certain  signs  that  indicate  neVve 
injury,  the  most  important  of  which  follow : 

1.  Muscular  wasting  as  compared  with  the  opposite  limb. 

2.  Abnormal  limitation  of  mobility  of  joints. 

3.  Tenderness  along  the  nerve  trunks. 

4.  The  reaction  of  degeneration. 

5.  Loss  of  epicritic  and  protopathic  sensibility. 

The  nerves  most  frequently  affected  are  the  ulnar,  musculo-spirai  and 
branches,  and  the  great  sciatic  and  its  branches.  Then  follow  in  order  of 
frequency  the  median,  brachial  plexus,  internal  cutaneous,  musculo-cutaneous, 
and  Cauda  equina. 

Treatment.  According  to  Ranvier,  Cajal  and  others,  it  is  known  that 
restitution  of  the  nerve  is  possible  only  when  the  central  end  can  send  out 
new  fibers  to  meet  the  peripheral  stump.  The  central  ganglia  cells  push  out 
new  nerve  fibers  as  long  as  there  is  no  resistance,  such  as  scar  tissue,  to  deflect 
the  new  nerve  fibers.  The  nerve  is  regenerated  by  those  fibers  which  reach 
the  cells  of  Schwann,  left  over  in  the  peripheral  degenerated  nerve.  From 
these  histological  facts,  two  operative  indications  are  deducted  (Edinger), 
(a)  to  remove  the  resistance  as  thoroughly  as  possible,  and  (b)  to  pave  the 
way  for  the  new  fibers  to  reach  the  peripheral  stump. 

Methods  of  operation.  In  fresh  wounds,  uninfected,  and  with  injuries  to 
nerves,  it  is  best  to  suture  the  ends  at  once,  where  possible,  with  the  finest  silk 
or  catgut.  As  present  war  wounds  are  usually  infected,  this  procedure  can 
rarely  be  instituted.  The  usual  case  is  that  in  which  more  or  less  extra-  or 
intra-neural  scar  tissue  is  present.  This  scar  tissue  must  be  very  carefully 
dissected  away  and  a  good  bed,  preferably  of  fascia,  provided. 

After  the  resection  of  the  scar  tissue,  there  may  be  such  a  distance  between 
the  two  stumps  that  primary  suture  is  impossible.  In  such  cases  it  is  neces- 
sary to  do  a  neuroplasty,  similar  to  the  usual  method  of  lengthening  tendons, 
or  to  graft  the  upper  and  lower  ends  into  an  adjacent  nerve  trunk.  Both 
methods  have  proved  successful  in  a  number  of  reported  instances,  although 
failures  are  also  recorded. 


PART  XII 

THE  SURGICAL  HOSPITAL 


In  order  to  do  surgical  work  successfully,  it  is  necessary  for  the  surgeon  to 
be  able  to  secure  for  his  patients  proper  hospital  care.  An  artisan  doing  his 
work  by  going  from  house  to  house  cannot  compete  with  another  who  does 
the  same  class  of  work  in  a  well  equipped  workshop,  and  the  latter  will  again 
do  better  work  in  his  own  shop  than  he  would  in  any  other  in  which  he  might 
execute  one  piece  of  work.  The  surgeon  of  average  ability  and  experience  will 
usually  do  much  better  work  in  his  own  hospital,  with  his  own  assistants  and 
nurses,  than  can  be  done  by  another,  for  instance,  of  much  greater  skill  in  a 
hospital  in  which  neither  the  nurses  nor  the  assistants  are  thoroughly  familiar 
with  his  methods  and  technique.  For  these  leading  reasons,  and  many  others 
which,  however,  refer  more  particularly  to  personal  comfort,  professional  repu- 
tation and  financial  success,  every  surgeon  should  have  a  hospital,  or  a  definite 
portion  of  a  hospital,  in  which  he  can  pursue  his  work  systematically  and 
after  some  definite  plan  that  is  in  keeping  with  his  technical  ability,  and  which 
will  enable  him  to  perform  the  immediate  work  he  has  to  do  in  the  best  pos- 
sible way,  and  also  enable  him  to  make  such  progress  from  year  to  year  as  is 
possible  under  the  conditions  surrounding.  Only  the  progressive  surgeon  can 
continue  to  prosper  under  existing  conditions  of  competition. 

In  planning  a  surgical  hospital,  or  a  surgical  department  of  a  general  hos- 
pital, it  is  important  to  secure  primarily  the  greatest  possible  facility  for  caring 
for  patients.  Facilities  which  will  give  the  patient  the  best  obtainable  condi- 
tions for  a  rapid  recovery,  combined  with  the  greatest  possible  comfort  while 
in  the  hospital.  At  the  same  time  it  is  important  to  keep  the  cost  of  construc- 
tion as  low  as  consistent  with  securing  the  above.  In  doing  this,  however,  it 
is  important  always  to  bear  in  mind  that  the  running  expenses  of  a  hospital 
amount  to  as  much  every  three  to  five  years  as  the  original  cost  of  the  build- 
ings, hence  it  is  of  the  greatest  importance  to  plan  construction  so  as  to  insure 
economj^  in  the  running  expenses  of  the  institution.  In  this  manner  a  given 
amount  of  money  will  readily  produce  much  greater  advantage  if  the  plans  are 
properly  made  than  if  little  or  no  attention  is  given  to  these  important  features. 

It  should  be  stated  here  that  it  is  always  wise  to  secure  expert  advice  in  the 
construction  of  hospitals.  No  one  would  think  of  employing  an  oculist  to 
remove  a  stone  from  the  ureter,  or  to  make  a  gastro-enterostomy,  and  still  it 
would  be  quite  as  reasonable  to  do  this  as  for  a  surgeon  who  has  had  no  expe- 
rience in  constructing  a  hospital  to  make  his  own  plans,  or  to  entrust  this  to 
an  architect  who  has  never  made  a  special  study  of  hospital  construction,  but 
rather  has  given  his  entire  attention  to  the  building  of  residences,  sfores  or 
manufacturing  plants. 

It  is  advisable  for  the  surgeon  to  make  his  own  outlines,  according  to  ar- 
rangements he  has  seen  in  other  hospitals,  then  to  have  a  local  architect  make 
preliminary  drawings.  Then  he  should  employ  the  best  available  architect 
who  has  made  a  special  study  of  hospital  construction  and  they  together  should 

787 


788 


THE  SURGICAL  HOSPITAL 


thoroughly  revise  such  plans.  Then  the  local  architect  should  carefully  com- 
plete these  drawings,  but  before  these  are  turned  over  to  the  builder  they 
should  again  be  corrected  in  every  detail  by  the  specialist  in  hospital  archi- 


A.  shows  the  amount  of  space  occupied  by  a  ten-story  building  in  the  middle  of  a  ten-acre 
lot,  extending  from  north  to  south,  so  that  all  the  rooms  have  either  east  or  west  sunlight  and 
the  hall  has  sunlight  from  the  south.  Such  a  building  would  supply  almost  dustless  air  in 
almost  any  location  if  shrubbery  and  trees  were  planted  along  the  edges  of  the  lot.  It  would 
be  much  more  sanitary  than  if  the  same  number  of  patients  were  housed  in  ten  one-story  build- 
ings, as  shown  in  B.,  and  the  cost  of  construction  and  maintenance  would  be  very  much  less 
in  the  former  than  in  the  latter. 


tecture.  "We  have  repeatedly  seen  this  course  followed  with  the  result  of  sav- 
ing from  twenty  to  fifty  per  cent,  in  cost  of  construction,  an  equal  increase  in 
efficiency  and  consequent  reduction  in  cost  of  maintenance  for  the  entire  time 
that  the  hospital  is  in  use  after  its  completion. 


THE  SUKGICAL  HOSPITAL 


789 


During  the  past  few  years  hundreds  upon  hundreds  of  new  hospitals  have 
been  constructed  in  the  various  American  cities  and  towns,  and  it  is  an  inter- 
esting fact  that  in  almost  every  instance  these  structures  have  been  planned  by 
people  who  had  previously  given  the  subject  of  hospital  construction  and  loca- 
tion little  if  any  attention. 

Architecture.  A  local  committee  usually  employs  a  local  architect  who 
consults  the  essays  on  hospital  construction  prepared  nearly  forty  years 
ago  by  the  authorities  of  Johns  Hopkins  Hospital.     {Hospital  Construciion  and 

■STgATMCOHA   Ho5PITv^L.-QT^/KCTMgO>\A.Al-T&TA.XAr<. 


[U] 


lO 


E;n-r<tA.NC:x. 


153LOCK   "Pl-AJi  'QHOWIHG    UHITS  ToTZ   U-LTlTylATTE. 'Pa./^H  . 

The  shaded  lines  show  the  portion  first  constructed. 

If  this  building  is  placed  in  the  position  shown  in  E  or  G,  every  portion  of  every  outside 
wall  will  be  covered  with  sunlight  at  some  time  of  the  day;  if  placed  as  at  F,  the  entire  north 
side  of  the  building  is  not  exposed  to  sunlight  at  any  time  of  day.  It  is  possible  to  overcome 
this  objection  by  placing  the  utilities,  like  elevators,  bath-rooms  and  serAdce-rooms,  in  this 
part  of  the  building  and  leaving  the  remaining  portions  for  rooms  and  wards  for  the  patients. 


Organization,  Baltimore,  1875).  He  may  even  go  so  far  as  to  visit  a  few  of  the 
existing  hospitals  nearby,  chiefly  for  the  inspection  of  apparatus  and  operating 
rooms.  He  may  also  get  the  advice  of  one  or  more  physicians  who  have  never 
given  the  slightest  attention  to  hospital  construction,  and  with  this  prelimi- 
nary preparation  the  building  is  planned  and  completed. 

The  result  will  depend  largely  upon  the  special  line  in  which  the  architect 
has  been  active.  If  he  has  been  in  the  habit  of  specializing  in  the  planning  of 
cottages  his  hospital  plans  will  contain  the  characteristics  of  a  cottage ;  if  he 
has  mostly  built  flat  or  apartment  buildings  their  special  features  will  be  con- 


790  THE  SURGICAL  HOSPITAL 

tained  in  the  plans  and  so  on  through  the  entire  list  of  architectural  specialties 
from  the  construction  of  grain  elevators  to  churches. 

In  making  an  investigation  concerning  the  construction  of  hospitals  in 
the  U.  S.,  Bertrand  E.  Taylor  (Brickhuikler,  March,  1904),  found  that  a  vast 
majority  of  all  hospitals  at  the  present  time  were  originally  constructed  for 
some  other  purpose,  old  buildings  having  been  adapted.  He  also  states  that 
the  new  hospitals  have  generally  been  designed  by  architects  of  brilliant  attain- 
ments, but  who  were  generally  totally  unfamiliar  with  even  the  rudiments  of 
hospital  requirements. 

The  excellent  work  of  Henry  C.  Burdett  {Hospitals  and  Asylums  of  the 
World,  London.  1893 j  is  sometimes  consulted,  but  this  again  simply  repeats 
the  ideas  which  were  laid  down  in  the  essays  just  mentioned.  The  same  is 
true  if  the  various  German  books  and  pamphlets  are  consulted,  for  in  all  of 
these  practically  the  plan  of  the  Hamburg  Hospital  at  Eppendorf  is  taken  as 
the  best  type,  and  this  was  completed  twenty-five  years  ago.  and  planned  long 
before  that  time. 

So  thoroughly  have  these  ideas  taken  root  that  in  many  instances  enor- 
mous sums  of  money  have  been  spent  with  the  result  that  all  of  the  patients 
are  compelled  to  exist  near  the  ground,  where  the  air  is  least  wholesome,  most 
thoroughly  laden  with  dampness  of  the  soil  and  with  street  dust.  Moreover, 
the  amount  of  sunlight  is  greatly  interfered  with,  because  so  large  a  propor- 
tion of  the  available  land  is  either  directly  covered  with  buildings  or  is  in 
the  shadow  of  the  large  number  of  small  buildings  required  to  house  the 
patients. 

We  refer,  of  course,  to  the  plan  of  building  a  large  number  of  one,  or 
one  and  a  half  story  pavilions,  which  has  of  late  become  especially  popular. 

As  an  example  we  may  take  the  new  hospital  for  the  city  of  Vienna.  That 
city  is  notoriously  dusty.  The  authorities  have  constructed  thirty-two  sep- 
arate, low  buildings  which  will  cover  a  great  portion  of  the  available  ground. 
It  is  necessary  to  place  some  of  these  buildings  relatively  near  the  sur- 
rounding streets,  thus  exposing  the  patients  not  only  to  the  noises  of  the 
streets,  but  to  the  dust  which  will  easily  rise  to  the  height  of  the  first  story. 

Were  it  contemplated  to  erect  instead  four  wings  of  the  same  size  of 
foundation,  each  eight  stories  high,  it  is  plain  that  the  distance  from  the 
surrounding  streets  could  be  increased  to  such  an  extent  that  by  proper 
planting  of  trees  and  shrubs  the  air  wouJd  be  so  thoroughly  filtered  by  the 
time  it  reached  the  buildings  that  it  would  be  practically  dust  free.  This 
would  be  true  especially  of  the  upper  floors,  but  even  the  first  floor  would  be 
greatly  removed  from  the  dust  and  noise  to  which  a  great  portion  of  all 
the  patients  are  exposed  under  the  present  idea. 

Location.  The  location  of  hospitals  is  determined  in  the  same  manner. 
It  is  chosen  because  it  is  cheap ;  because  some  philanthropic  person  has 
donated  it  to  the  committee :  because  some  influential  member  wishes  to  dispose 
of  a  particular  piece  of  property ;  because  it  is  in  the  vicinity  of  some  medi- 
cal college  or  some  selfish  member  of  the  medical  staff  desires  the  hospital 
convenient  to  his  residence  in  a  large  proportion  of  cases ;  and  only  rarely 
because  it  is  especially  suited  for  a  hospital  site.  In  the  smaller  towns  very 
bad  locations  are  usually  selected  in  all  cases  in  which  the  advice  of  location 
is  left  with  the  physicians,  as  from  lack  of  experience  they  imagine  that  the 
hospital  will  be  more  prosperous  if  located  near  the  business  center  of  the 
town.  They  also  have  the  foolish  idea  that  the  hospital  must  be  within  a  few 
blocks  of  their  offices  or  residences  in  order  that  they  may  readily  be  avail- 
able in  cases  of  emergencies,  forgetting  that  emergencies  are  an  unimportant 
factor  and  rarely  occur  during  office  hours. 

There  are  certain  fundamental  principles  which  should  be  borne  in  mind 


THE  SURGICAL  HOSPITAL 


791 


CD 


fD 


0  <  I  s- '  5: 

Pj  p   P  en 

■^        p-i.  Si 

2  ^  ®       S.^ 

rt-  Cr  CD    ^  rt- 

o  £  &^  s  r 

P    CD    CO    O  v5    ^ 
rt-   r^  S"  St  CD  '=<^ 

cr  o 


CD 


fi,  CD 


.  CD 


5    CD    B    Cl    n    ^ 

!2. 3  H  &  a  s- 


O    tr  CD    " 


_   tr  CD 

Hs  (-:,■ 
H  q  S 


S-  O   P 


^    P. 


B" " 


CD 


CD 


C   ^         !r    3   CD 


2:i :. 


CD 


P  Cfq    CD 


^    "-i   p    . , 

5"§-^^  -3 

crq  g       JO  »  5: 

as  J°  tT'        C5  i^^ 

'^         '-'   p   p  S' 

P    M  ^    q  '^ 

CD    5    2-  P    P  Hs 

•    :3.  a>  goq  ^ 

„    C   Pj  o 


O    t^ 


3  5'  ^  -"  " 
-"crq 


^  -  ^  1  g 


792  THE  SURGICAL  HOSPITAL 

in  the  selection  of  a  site  for  a  hospital,  no  matter  whether  it  be  located  in 
a  great  city  or  a  country  town.  Of  course  all  conditions  are  only  relative. 
It  is  but  rarely  possible  to  obtain  the  ideal  in  the  selection  of  a  site,  which 
has  indeed  been  practically  obtained  in  a  few  instances,  of  which  we  men- 
tion that  of  the  Royal  Victoria  Hospital,  in  Montreal,  but  it  is  possible  in 
every  city  or  town  to  approximate  these  conditions  much  more  closely  than 
has  been  done  in  ninety  per  cent,  of  all  hospitals.  It  should  be  stated  here 
that  this  criticism  applies  to  a  much  less  extent  to  institutions  conducted  by 
sisterhoods  than  any  others,  as  their  selection  of  sites  has  in  many  cases  been 
based  upon  recognized  principles. 

Absence  of  noise.  The  site  should  be  in  a  quiet  portion  of  the  city  or  town, 
away  from  noisy  railroad  tracks,  street  cars  or  elevated  railroads,  or  factories. 
In  country  towns  this  may  be  accomplished  easily,  and  in  great  cities  the  loca- 
tion can  be  chosen  at  least  three  blocks  away  from  ordinary  railroad  tracks. 

(Nine-tenths  of  all  of  the  larger  hospitals  of  Chicago  are  located  directly 
upon  one  or  two  street  car  tracks  or  within  two  blocks  of  an  ordinary  rail- 
road track.) 

Absence  of  dust.  Its  location  should  be  so  chosen  as  to  reduce  exposure 
to  street  dust  to  a  minimum.  This  can  best  be  accomplished  by  selecting  a 
high  knoll  in  a  hilly  town,  or  by  setting  the  building  back  from  the  street 
a  considerable  distance  in  a  flat  city  and  planting  trees  and  shrubs  which 
will  act  as  natural  filters  along  the  edge  of  the  grounds  along  the  streets,  and 
by  erecting  high  buildings.  Very  little  street  dust  relatively,  rises  above  the 
second  story,  so  that  the  higher  stories  are  nearly  free  from  this  contamina- 
tion. In  every  city  there  are  streets  that  are  comparatively  little  used.  This 
fact  should  be  considered  favorably  in  the  selection  of  a  hospital  site. 

Sunlight.  It  is  so  extremely  simple  to  plan  a  building  so  that  every 
room  and  ward  will  have  sunlight  during  some  portion  of  the  day  that  it  is 
surprising  to  find  many  hospital  buildings  in  which  one-third  or  more  of  the 
rooms  never  have  a  ray  of  sunlight. 

In  order  to  have  sunlight  in  each  room  and  ward  it  is  necessary  only  to 
construct  all  buildings  or  pavilions  from  north  to  south,  which  will  give  to 
one  long  side  sunlight  in  the  morning  and  to  the  other  side  in  the  afternoon. 

The  importance  of  sunlight,  its  distribution,  the  production  and  depth 
of  shadows,  together  with  the  bearing  this  subject  has  upon  the  planning 
of  hospitals,  has  been  studied  and  illustrated  with  great  care  by  Wm.  Atkin- 
son, architect  (Brickhuilder,  July,  1903).  The  various  shapes  of  wings  have 
been  thoroughly  discussed,  with  a  careful  consideration  of  the  amount  of  sun- 
light and  shadow  obtained  by  buildings  of  the  various  forms  usually  em- 
ployed. This  feature  has  received  careful  attention  in  the  work  on  the 
Organization,  Construction  and  Management  of  Hospitals  (Ochsner  and  Sturm). 

At  this  point  it  may  be  well  to  direct  attention  to  the  fact  that  in  long 
wings  with  a  central  hall,  with  wards  or  rooms  arranged  on  either  side  of 
such  hall,  two  outside  and  two  inside  walls  will  house  as  many  patients  as 
four  outside  and  two  inside  walls  would  w^ere  the  wards  or  rooms  arranged 
along  one  outside  wall  and  a  hall  placed  along  the  other  outside  wall,  and 
separated  from  the  wards  or  rooms  by  an  inside  partition.  This  is  plainly 
illustrated  in  figures  shown,  which  represent  two  typical  plans.  The  first 
shows  a  hospital  extending  from  north  to  south  in  which  every  room  or  ward 
is  exposed  to  sunlight  either  in  the  forenoon  or  afternoon,  and  the  hall  during 
midday.  The  next  represents  a  building  extending  from  east  to  west,  with  all 
of  the  rooms  and  wards  exposed  to  the  sun  from  the  south  and  with  a  hall 
extending  along  the  northern  wall. 


THE  SURGICAL  HOSPITAL 


793 


CD 


P    _ 
?5 


SO        hrj 


^i3 
f^^ 


d  S 


^^ 

CO     S 

p& 

CD    O 

CD  a 


CD 


Cti 
O    fj 

QK9 


<S5 


Jf  CD      a 

?D    CO  J-. 


CD    S 
M.  P 

P  1=3 


1    o 


P5 
P 


794  THE  SURGICAL  HOSPITAL 

It  is  plain  that  the  expense  of  constructing  a  hospital  for  a  given  num- 
ber of  beds  must  be  at  least  sixty  per  cent,  greater  if  the  latter  is  followed 
than  with  the  former,  because  the  additional  walls  amount  to  fifty  per 
cent.,  and  there  will  be  required  double  the  amount  of  outside  walls  which 
are,  of  course,  much  more  expensive.  Moreover  the  same  area  of  hall  space 
serves  twice  the  number  of  beds  in  No.  1  that  it  serves  in  No.  2, 

But  this  is  not  all ;  the  distance  of  travel  required  by  those  employed  in 
caring  for  the  sick  is  just  doubled.  The  area  of  the  hall  which  must  be  kept 
clean  is  twice  as  great.  The  number  of  windows  which  must  be  kept  clean 
is  approximateh'  twice  as  great. 

Aside  from  this  there  is  the  disadvantage  in  plan  2  from  the  fact  that 
twice  the  surface  of  outside  wall  is  exposed  to  the  weather  and  twice  the 
amount  of  hall  space  must  be  heated. 

Against  this  we  have  the  fact  that  in  plan  2  every  room  is  exposed  to 
the  south.  In  most  climates  it  is  likely  that  exposure  to  sunlight  for  half 
the  day  is  equally  satisfactory^  in  all  except  the  summer  season,  and  to  be 
preferred  in  this  season. 

It  seems  plain  consequentl}"  that  plan  No.  1  is  much  to  be  preferred. 
Freedom  from  smoke.     In  many  of  our  great   cities  there  are  locations 
in  which  there  is  but  rarely  any  sunshine  because  of  the  presence  of  coal 
smoke  from  large  furnaces  and  factories.     These  locations  should  of  course 
be  avoided  in  selecting  hospital  sites. 

It  is  well  to  note  the  general  direction  of  winds  and  to  bear  in  mind  the 
fact  that  smoke,  although  very  diffusible  in  the  air,  will  not  be  distributed 
to  any  considerable  extent  against  even  the  slightest  current  in  the  air.  It 
is  also  important  to  bear  in  mind  that  Avhen  the  air  is  apparently  still  it 
nevertheless  travels  at  a  rate  of  about  one  hundred  feet  per  minute,  or  about 
as  one  would  move  in  sauntering  along  the  street,  taking  a  step  in  two  seconds. 

Again,  in  protecting  the  institution  against  smoke  from  any  given  source 
one  may  obtain  a  fair  idea  of  the  entire  amount  that  will  be  delivered  to  an 
institution  in  still  air  by  taking  the  distance  from  that  source  as  the  radius  of 
a  circle  of  which  the  segment  corresponding  to  the  length  of  the  institution 
indicates  the  relative  proportion  of  the  smoke  carried  to  this  distance  which 
will  be  delivered  to  the  institution. 

This  illustration  is  employed  to  show  how  little  of  the  entire  volume  of 
smoke  will  be  delivered  to  any  given  space  which  may  be  occupied  by  the 
hospital  in  still  air,  and  if  the  location  is  wisely  chosen  with  this  point  in  view 
it  is  usually  possible  to  have  the  hospital  on  the  windward  side  of  the  sources 
of  especially  great  smoke  producers  during  the  prevailing  winds,  and  thus 
the  smoke  nuisance  will  not  be  so  much  of  an  annoyance  as  one  might  expect. 
Fortunately  smoke  is  usually  produced  in  certain  centers  so  that  one  may 
practically  avoid  them  to  a  very  considerable  extent,  by  the  careful  selection 
of  the  site. 

Accessibility.  "Without  disregarding  the  principles  already  mentioned  it 
is  important  that  hospitals  should  be  accessible  to  patients,  to  their  friends, 
and  to  the  officers  of  the  hospital  staff.  This  is  important  because  it  is  not 
well  for  many  acute  cases,  such  as  pneumonia,  typhoid  fever,  peritonitis,  etc., 
to  be  transported  a  great  distance.  Since  the  introduction  of  properly  con- 
structed ambulances  in  which  the  stretchers  are  suspended  from  the  roof 
upon  spiral  springs,  and  in  which  the  wheels  are  provided  with  rubber  tires, 
the  objection  to  transportation  for  a  distance  of  several  miles  has  very  little 
real  weight,  provided  the  ambulance  service  is  properly  oreanized.  _  "With 
modern  automobile  ambulances  a  distance  of  ten  miles  is  really  of  no  impor- 
tance if  the  roads  are  good.    In  large  cities  ambulances  should  be  built  so  that 


THE  SURGICAL  HOSPITAL  795 

the  wheels  can  run  on  street  car  rails,  which  will  make  the  selection  of  smooth 
roads  always  possible. 

Great  distances  are  a  hardship  to  the  friends  of  patients  who  belong  to 
the  working  classes,  because  of  the  time  and  expense  involved  in  visiting  such 
hospitals,  and  although  it  is  usually  better  for  the  patient  if  his  visitors  are 
few,  still  the  fact  that  it  is  difficult  for  friends  to  reach  a  distant  hospital  fre- 
quently serves  as  a  sufficient  ground  for  them  to  prevent  patients  who  could 
be  best  treated  in  a  hospital  from  availing  themselves  of  this  blessing. 

Great  distance  also  often  prevents  physicians  and  surgeons  of  the  great- 
est learning  and  skill  from  serving  upon  a  hospital  staff,  as  the  time  spent  in 
going  to  and  from  the  hospital  seems  too  great  in  proportion  to  the  time  spent 
in  actual  work  therein.  But  since  the  adoption  of  automobiles  has  become  so 
general,  this  objection  no  longer  requires  consideration,  except  in  very  cold 
climates  where  their  use  is  not  profitable  during  the  winter  months. 

Hospitals  should  be  located  in  residence  districts  of  cities  and  towns,  as 
the  same  conditions  which  make  a  location  desirable  for  residence,  make  it 
favorable  for  a  hospital.  The  nearer  such  a  site  is  to  a  park,  a  lake,  the  high 
banks  of  a  river,  or  the  seashore,  the  better. 

Size  of  grounds.  It  is  of  the  greatest  importance  to  have  a  good-sized  area 
of  land,  as  this  will  prevent  the  contamination  of  the  air  by  immediate  neigh- 
bors. It  will  make  a  free  sweep  of  air  possible.  The  buildings  can  be  set 
back  on  the  grounds  so  as  to  sufficiently  secure  some  of  the  conditions  men- 
tioned above. 

A  hospital  should  never  be  placed  between  a  number  of  large  buildings 
in  the  middle  of  a  block — a  position  too  frequently  chosen  at  the  present  time. 

Even  in  the  smaller  villages  one  frequently  finds  hospitals  almost  com- 
pletely filling  the  grounds.  It  is  practically  always  possible  to  secure  at  least 
five  acres  of  land  for  hospital  grounds,  as  in  most  communities  this  land  is 
not  subject  to  taxation,  and  it  is  always  a  good  investment. 

Bmldings.  Having  chosen  a  suitable  location  the  question  of  planning 
the  buildings  themselves  must  be  considered. 

Forty  years  ago  the  theory  of  isolation  of  all  portions  of  hospitals  from 
all  other  portions  received  special  favor  owing  to  the  views  then  held  regard- 
ing contamination  and  infection.  It  was  supposed  that  an  ideal  condition 
would  be  established  if  each  patient  could  occupy  a  separate  building  sup- 
plied with  all  conveniences. 

As  this  was  not  practicable  it  resulted  in  the  planning  of  hospitals  com- 
posed of  numerous  small  separate  buildings,  usually  one  or  two  stories  in 
height.  There  developed  a  fear  of  scattering  disease  from  one  patient  to 
another  through  the  medium  of  air  contamination.  Singularly  enough  this 
view  was  due  to  the  fact  that  the  real  cause  of  contagion  had  not  as  yet  been 
established  and  it  was  simply  known  that  some  diseases  were  transmissible 
from  patient  to  patient.  It  was  not  then  known  that  definite  organisms  must 
be  carried  from  one  patient  to  the  other  in  order  to  cause  this  transmission 
of  certain  diseases.  It  is  plain  that  if  those  who  cared  for  patients  in  one 
pavilion  could  not  come  in  contact  with  patients  in  another  pavilion,  the  lat- 
ter would  not  be  infected  from  the  former. 

In  this  manner  a  practical  solution  was  found,  although  this  had  not  been 
based  upon  a  scientific  knowledge  of  existing  facts. 

Although  we  know  that  there  is  a  definite  difference  between  diseases 
transmitted  from  patient  to  patient,  and  the  very  much  larger  class  in  which 
this  is  not  possible,  the  fundamental  idea  underlying  all  hospital  construc- 
tion still  centers  about  this  theory  of  air  contamination. 

In  reviewing  recent  literature  on  hospital  construction  one  constantly  finds 
a  reiteration  of  this  idea.    The  various  authors  seem  to  be  impressed  with  the 


796 


THE  SURGICAL  HOSPITAL 


A    Gy/iocological  fcf 
Obstltdical-  Hospital  . 


Top  Floor  F^la/j 


This  represents  the  top  floor  of  a  very  convenient  small  hospital  extending  north  and  south. 
At  the  north  end  of  the  building  are  located  two  operating  rooms  with  large  north  windows 
and  large  skylights  and  with  an  intervening  sterilizing  room.  If  the  hospital  is  also  to 
accommodate  obstetrical  patients,  the  next  room  on  the  east  side  may  be  used  for  obstetrical 
operations,  otherwise  it  may  be  used  as  a  recovery  room.  Directly  to  the  north  of  the  elevator 
the  hall  is  divided  into  a  north  portion  to  be  used  in  connection  with  the  surgical  ser\ice, 
and  a  south  portion  to  be  used  in  connection  with,  kitchen  and  dining  rooms.  This  partition 
is  not  shown  in  the  figure. 

A  hospital  built  according  to  this  plan  has  been  in  operation  for  several  years  and  is 
eminently  satisfactory. 


THE  SURGICAL  HOSPITAL  797 

danger  of  the  communication  of  disease  from  one  patient  to  another,  even  in 
non-contagious  and  non-infectious  diseases,  and  this  is  an  idea  expressed  not 
only  by  architects  whose  ignorance  in  this  direction  would  be  excusable,  but 
also  by  members  of  the  medical  profession.  And  yet  when  one  asks  hospital 
physicians  of  large  experience  for  an  example  of  such  an  occurrence  among 
the  thousands  of  cases  observed  one-  iinds  that  no  such  instances  have  hap- 
pened in  the  actual  experience  of  those  with  vast  practice. 

The  knowledge  of  this  fact  should  make  it  plain  that  there  should  in  the 
first  place  be  a  definite  isolation  of  all  cases  whose  disease  can  be  transmitted 
by  contact  or  by  infection,  and  on  the  other  hand  that  the  other  cases  should 
be  placed  in  buildings  constructed  with  a  view  to  securing  conditions  favor- 
able to  the  treatment  of  the  diseases  involved,  and  not  with  a  view  of  securing 
a  degree  of  isolation  which  in  this  very  large  class  is  of  absolutely  no  value, 
but  of  very  great  inconvenience  and  expense. 

These  patients  need  an  abundance  of  clean  air,  sunlight,  proper  food  and 
excellent  nursing  in  clean  rooms,  properly  heated,  and  as  little  disturbed  by 
noises  as  possible.     They  should  also  be  protected  against  danger  from  fire. 

All  of  these  requirements  should  be  secured  at  as  slight  an  expense  as  pos- 
sible, as  all  available  funds  can  ahvays  be  employed  with  benefit  even  though 
no  money  be  expended  unnecessarily.  The  follies  which  have  been  committed 
in  the  way  of  obtaining  a  very  slight  amount  of  benefit  to  the  patients  for  the 
amount  of  money  expended  are  extraordinary. 

It  is  necessary  to  study  the  expense,  1st,  from  the  standpoint  of  primary 
cost  of  construction,  and  2nd,  from  the  standpoint  of  cost  of  maintenance. 

In  constructing  buildings  to  house  a  given  number  of  patients  the  first  and 
the  last  stories  are  always  of  the  greatest  expense,  as  the  first  story  implies 
the  cost  of  a  foundation  with  its  system  of  drains  for  the  proper  disposition  of 
the  sewage.  The  last  story  is  again  expensive  because  of  the  necessity  of 
covering  it  with  a  suitable  roof. 

These  items  may  be  divided  into  units  of  cost  where  the  foundation  proper 
(footings)  are  taken  as  one,  the  cellar  or  foundation  walls  as  one  and  the  first 
story  as  one,  the  superstructure  (roof,  walls,  etc.)  as  one.  This  makes  a  total 
of  four  units  for  the  first  story  covered,  or  for  a  one  story  building.  Each 
additional  story  between  the  first  three  and  the  last  is  an  added  unit,  so  that 
in  a  six  story  building  we  have  the  original  four  plus  the  five  added  stories, 
making  nine  as  against  twenty-four  units  for  six  pavilions  of  the  same  area. 
This  will  be  found  to  be  a  fair  proportion. 

The  intermediate  stories  require  no  foundation,  the  same  sewer  system 
which  serves  the  first  story  can  be  made  to  serve  all  of  the  succeeding  stories, 
and  the  roof  covering  the  last  story  will  serve  all  the  intervening  ones.  The 
only  difference  lies  in  the  strength  of  the  foundation  and  the  thickness  of  the 
walls,  which  must  be  proportionate  to  the  height  of  the  building. 

It  is  also  absolutely  necessary  that  a  high  building  be  supplied  with  an 
elevator,  and  that  its  construction  be  thoroughly  fire-proof,  both  conditions 
not  required  in  a  one-story  building.  But  nevertheless  the  cost  of  construc- 
tion of  one  of  these  high  buildings  is  much  less  in  proportion  to  the  num- 
ber of  patients  housed  than  that  of  one-story  buildings. 

It  will  readily  be  seen  that  the  primary  cost  and  maintenance  of  the  plant 
will  be  greater  in  one  story  pavilion  hospitals  than  in  superimposed  stories, 
as  in  the  latter  the  system  is  simpler  in  construction,  more  direct  and  so  more 
economical  in  all  ways.  This  holds  especially  also  for  the  plumbing,  as  the 
superimposed  bath-rooms,  etc.,  need  but  one  stack  and  vent  for  each  separate 
tier  and  can  be  run  more  advantageously.  Again  in  the  heating  of  these  build- 
ings the  amount  of  heat  wasted  in  cold  weather  is  much  greater  in  one-story 


798 


THE  SURGICAL  HOSPITAL 


buildings  because  of  the  relatively  greater  amount  of  surface  exposed  to  the 
outer  air. 

The  difference  in  cost  of  construction  between  fireproof  and  non-fireproof 
is    decreasing    constantly    especially    so    since    many    of    the    new    so-called 


Meyer  J.  Sturm    Architect 
(From  Organization,  Construction,  and  Management  of  Hospitals,  Ochsner  and  Sturm.) 

Represents  one  floor  of  a  U-shaped  hospital  of  many  stories,  which  combines  great  con- 
venience, perfect  arrangement  for  sunlight,  economy  in  conduct,  ser\ace,  heating,  and  lighting. 
It  is  an  ideal  plan  for  a  hospital  for  large  cities  in  which  excellence  of  service  and  economy 
in  cost  of  construction,  cost  of  upkeep,  and  cost  of  maintenance  are  important  elements.  R 
represents  rooms,  W  small  private  wards,  E  rooms  for  eye  patients,  S  service  room,  D  dressing 
and  examining  room,  T  toilet,  L  elevator,  V  veranda.  By  removing  the  partitions  between 
two  or  more  of  the  rooms  E,  wards  may  be  arranged  of  any  desirable  size.  All  rooms  except 
those  used  for  eye  patients  have  sunlight  during  some  part  of  the  day. 

"armored  concrete"  constructions  have  been  brought  forward.  Some  of  these 
are  the  equal  of  any  construction  known  and  cost  but  little  if  any  more  than 
first-class  frame  construction  in  larger  buildings.  This  is  more  evident  since 
wood  has  become  scarce  and  correspondingly  costly  in  the  last  few  years. 
This  is  of  very  great  importance  as  it  makes  it  possible  to  obtain  the  advantages 
of  housing  the  patients  in  a  high  building  away  from  the  noise  and  dust  of  the 


THE  SURGICAL  HOSPITAL  799 

streets  and  the  dampness  of  the  soil,  without  exposing  them  to  the  dangers 
from  fire  and  without  increasing  the  cost  of  construction  to  an  unreasonable 
amount. 

The  use  of  the  modern  elevator  and  the  automatic  dumb-waiter  makes 
it  possible  to  care  for  patients  in  a  building  of  a  number  of  stories  at  a  much 
smaller  expense  than  when  housed  in  a  number  of  separate  cottages. 

There  is  one  great  danger  in  the  adoption  of  high  buildings  for  hospitals 
in  the  fact  that  there  is  a  great  temptation  to  decrease  the  area  of  the  land 
upon  which  the  hospital  is  built,  while  increasing  the  height  of  the  building. 
This  would,  of  course,  be  a  fatal  error  as  it  would  destroy  the  advantages  to 
be  gained  from  high  buildings,  especially  if  the  neighboring  buildings  were 
also  high. 

The  nearest  building  should  be  twice  the  distance  of  its  height  away  from 
the  hospital  in  order  that  there  be  no  serious  interference  with  sunlight  and 
with  the  air  supply.  It  is  important  in  designing  hospitals  to  arrange  a  fiat 
roof  properly  planned  to  serve  for  an  out-door  sleeping  pavilion.  In  this  way 
the  best  possible  facilities  can  be  obtained  for  patients  to  recover  from  anes- 
thesia after  operations  and  for  the  care  of  other  patients  who  are  best  off  in 
the  open  air.    Of  course,  the  elevator  and  all  other  utilities  must  be  provided. 

Shape  of  the  building — ground  plan.  Much  attention  has  been  given  to 
the  perfection  of  ideal  ground-plans  for  hospital  buildings.  "William  Atkinson 
states  the  principles  to  be  observed  in  the  following  concise  manner:  "First. 
To  secure  a  large  amount  of  sunlight  for  each  building.  Second.  To  impede 
as  little  as  possible  the  circulation  of  air  in  and  about  the  building.  Third. 
To  provide  for  the  future  enlargement  of  the  hospital.  Fourth.  To  promote 
convenience  and  economy"  of  administration." 

It  is  plain,  that  with  a  building  a  number  of  stories  high,  all  of  these  funda- 
mental principles  may  be  solved  in  the  simplest  possible  manner. 

First.  A  building  constructed  on  the  general  plan  indicated  in  plan  1 
furnishes  a  large  amount  of  sunlight  for  every  room  or  ward,  as  well  as  for 
the  hall.  It  is  important,  however,  that  the  hall  extend  the  entire  length  of 
the  building  and  that  it  be  not  obstructed  by  end-rooms  or  projecting  walls 
at  any  point  in  its  extent.  It  is  best  to  construct  the  end  of  the  hall  almost 
entirely  of  windows  and  large  glass  doors  by  means  of  which  patients  can  be 
wheeled  onto  the  porches. 

Second.    The  higher  the  building  the  less  will  be  the  obstruction  to  the  air. 

Third.  Future  enlargement  may  be  accomplished  by  adding  more  stories, 
provided  the  foundation  is  built  sufficiently  heavy  to  permit  this. 

Fourth.     Being  compact  it  must  be  convenient  and  economical  to  manage. 

The  same  author  gives  a  sun  plan  of  the  various  typical  forms  AA'hich  may 
be  given  to  a  ground  plan,  illustrating  with  excellent  diagrams  the  amount 
of  sunlight  as  well  as  the  extent  and  the  depth  of  shadows  produced  by  each 
form. 

A  study  of  the  diagrams  will  convince  any  one  that  the  form  indicated 
in  the  plans  shown  contains  the  greatest  number  of  advantages.  This  plan  can 
be  carried  out  by  simply  building  a  single  pavilion  as  shown,  or  two  or  more 
of  these  pavilions  may  be  built  in  a  row  with  a  sufficient  space  between. 

These  plans  may  all  be  united  by  a  one  story  corridor,  or  building,  which 
should  preferably  be  placed  at  the  north  of  the  pavilions  in  order  not  to  throw 
a  shadow  upon  the  land  between  the  various  pavilions.  In  this  way  another 
means  of  enlarging  the  institution  by  adding  further  pavilions  may  be 
provided. 

Or  they  may  be  placed  in  the  form  shown  herewith,  the  open  court  facing 
soutli,  or  better  still,  a  little  east  or  west  of  south.    Next  cut  gives  a  plan  for 


800 


THE  SURGICAL  HOSPITAL 


a  small  country  hospital  which  represents  the  same  principle.     This  building' 
must  of  course  also  extend  from  north  to  south. 

In  large  institutions  for  the  care  of  the  sick  in  great  cities  it  is  well  to 
consider  a  ground  plan,  as  next  shown,  in  which  one  wing  or  tier  of 
pavilions  is  intended  for  male,  the  other  for  female,  patients,  the  administra- 
tion building  being  placed  between  these  two  wings  at  an  equal  distance  from 
each. 

Aside  from  providing  for  the  housing  of  the  patients  it  is  necessary  to 
make  provision  for  the  housing  of  the  officers  of  the  institution,  the  resident 
medical  staff,  the  nurses  and  the  servants.     Provision  must  also  be  made  forj 


5EC0/1D  Floor  Pla/j 

A   Cou/iTPY  Hospital 

(Ey  courtesy  of  M.  J.  Sturm,  hospital  architect.) 

We  have  here  a  small  hospital  for  a  small  country  town.  The  building  extends  north  and 
south,  and  thus  t-upplies  sunlight  for  all  rooms  and  for  the  hall,  which  must  have  large  glass 
doors  at  each  end.  The  building  may  be  built  one,  two,  or  three  stories  high.  It  has  all 
facilities  of  the  modern  city  hospital. 


the  administrative  offices,  for  the  kitchen,  laundry  and  boilers  supplying  heat 
and  steam  power. 

If  but  a  single,  many-storied  building  is  chosen  it  is  well  to  place  the  of- 
fices in  the  first  floor,  as  well  as  the  rooms  for  the  house  stafi^,  the  drug  room, 
laboratories  and  the  examining  rooms,  as  this  places  the  patients  in  the  higher 
stories  where  they  are  away  from  the  disturbances  naturally  occurring  on 
the  first  floor. 

It  is  usually  better  to  house  the  servants  and  nurses  in  a  separate  building, 
so  as  to  compel  them  to  be  away  from  the  hospital  proper  during  their  time 
of  rest. 

It  is,  however,  often  more  convenient  to  build  the  original  hospital  build- 


THE  SURGICAL  HOSPITAL  801 

ing  sufficiently  large  to  house  the  patients  as  well  as  the  servants  and  nurses 
at  first,  and  as  the  latter  space  is  required  for  patients,  to  then  prepare  sep- 
arate quarters  for  the  nurses  and  servants. 

Kitchen.  In  such  a  building  the  kitchen  should  be  in  the  top  story,  con- 
nected with  all  the  stories  by  means  of  a  dumb-waiter,  each  story  having 
besides  its  own  diet  kitchen  and  nurses'  room.  This  prevents  the  annoyance 
which  invariably  exists  from  the  odors  of  cooking  when  the  kitchen  is  in  any 
other  portion  of  the  building. 

Operating  rooms.  The  operating  rooms  should  also  be  in  the  uppermost 
story  in  order  to  secure  the  air  freest  from  dust  and  to  prevent  annoyance  of 
the  other  patients  during  operations,  and  so  the  principal  light  for  operat- 
ing may  be  obtained  through  north  skylights. 

Recovery  rooms.  It  is  well  to  provide  a  number  of  rooms  in  this  story  in 
which  patients  may  be  kept  twenty-four  hours,  or  longer,  after  the  operations, 
so  as  to  prevent  the  disturbance  of  other  patients  in  the  hospital  by  those  who 
have  just  been  operated. 

In  this  manner  all  of  the  business  of  the  hospital  at  all  likely  to  disturb 
patients  is  conducted  in  the  first  and  last  stories  of  the  building,  as  far  as 
possible  away  from  the  inmates. 

Heating.  The  problem  of  heating  depends  largely  upon  the  climate  in 
which  the  hospital  is  located.  In  most  cities  in  this  country  it  is  necessary 
to  provide  efficient  means  of  heating  hospitals  during  the  cold  season  of  the 
year. 

The  most  economical  form  of  heating  in  the  colder  portions  of  this  country 
is  by  direct  radiation  from  steam  coils,  in  the  warmer  portions  of  the  country 
from  hot  water  coils. 

There  is  no  doubt  but  that  air  which  has  come  directly  in  contact  with 
steam  coils  heated  to  212°  F.  is  not  nearly  as  wholesome  as  that  which  has  not 
been  exposed  to  so  high  a  degree  of  heat.  With  the  ordinary  steam  coil  there 
is,  however,  only  a  small  proportion  of  the  air  contained  in  a  room  which 
comes  directly  in  contact  with  the  coils.  The  greater  portion  of  the  entire 
amount  of  the  air  in  a  room  being  heated  by  contact  with  air  nearer  the  coil 
which  has  been  heated,  consequently  only  a  portion  of  the  air  is  spoiled  by 
being  overheated  by  this  system. 

All  systems  of  combined  heating  and  ventilation  by  means  of  indirect 
heat  with  forced  ventilation  are  extremely  expensive  and  very  unsatisfac- 
tory and  should  be  absolutely  condemned  in  hospital  construction. 

Ventilation.  The  question  of  ventilation  is  usually  discussed  in  connec- 
tion with  heating,  because  in  cold  weather  the  fresh  air  brought  into  a  room 
must  first  be  heated  in  some  manner  before  being  delivered  to  the  patient. 

In  natural  ventilation,  which  occurs  through  the  walls  of  the  buildings, 
or  through  cracks  about  the  doors  and  windows,  the  cold  air  entering  is 
heated  by  coming  in  contact  with  the  air  already  in  the  room. 

Artificial  ventilation.  In  artificial  ventilation  there  are  still  many  practical 
problems  which  have  not  been  definitely  settled. 

This  kind  of  ventilation  may  be  accomplished  by  removing  the  air  in  the 
room  by  means  of  fans,  or  through  heated  flues  in  which  a  draft  is  caused 
by  the  fact  that  hot  air  rises,  because  of  its  decrease  in  weight,  due  to 
expansion. 

The  space  occupied  by  the  air  removed  from  a  room  by  either  of  these 
methods  will  be  filled  with  air  coming  from  without,  either  through  openings 
provided  at  points  at  which  the  cold  air  has  to  pass  over  heated  radiators,  or 
through  a  main  duct  above  the  roof,  and  necessary  heating  coils  below  the 
same  to  a  settling  chamber,  and  then  by  smaller  ducts  to  the  various  rooms. 

Another  method  consists  in  forcing  air  by  the  use  of  fans  through  a  cham- 


802 


THE  SURGICAL  HOSPITAL 


THE  SUEGICAL  HOSPITAL  803 

ber  heated  by  coils,  thence  through  flues  into  the  various  rooms  and  wards. 
This  plan  may  be  employed  alone  or  in  combination  with  the  methods  just 
mentioned,  by  means  of  which  the  bad  air  is  drawn  out  of  the  rooms.  But  this 
method  has  among  its  leading  drawbacks  this,  that  a  constant  temperature 
cannot  be  maintained,  owing  to  external  and  internal  variations  and  conditions. 
(There  are  always  air  spaces  which  contain  air  that  can  be  displaced 
only  with  difficulty,  while  there  are  other  spaces  in  which  the  air  can  be 
changed  easily,  consequently  the  fresh  air  will  constantly  be  forced  into 
spaces  which  are  least  in  need  of  a  change,  while  other  portions  of  the  room 
will  continue  to  contain  vitiated  air.) 

If  this  plan  is  chosen,  it  is  important  to  take  the  air  from  a  high  point 
and  never  from  the  level  of  the  ground,  because  in  this  manner  air  relatively 
free  from  dust  and  moisture  of  the  soil  may  be  obtained. 

It  is,  however,  important  that  the  intake  be  at  a  point  where  the  air  is  not 
vitiated  by  the  bad  air  forced  out  of  the  building,  or  by  smoke  from  the  chim- 
neys, or  sewer  gas  from  the  soil  pipes  which  project  beyond  the  roof.  This 
may  be  accomplished  by  placing  the  intake  to  the  windward  side  of  the  build- 
ing during  the  cold  season  of  the  year,  for  it  is  during  such  season  that  the 
forced  ventilation  will  be  in  use. 

The  heat  chamber  through  which  the  air  is  forced  should  be  supplied  with 
hot  water  pipes  in  which  the  heat  is  regulated  so  as  not  to  exceed  160°  F.,  as 
air  blown  over  pipes  heated  with  steam  to  212°  F.,  loses  much  of  the  invigorat- 
ing effect  obtainable  from  fresh  air. 

Theoretically  it  has  seemed  that  a  system  which  combines  the  plan  of 
withdrawing  the  vitiated  air  from  the  rooms  by  means  of  a  system  of  tubes, 
and  fans  which  force  into  the  rooms  at  the  same  time  a  sufficient  amount  of 
air  taken  from  a  point  at  which  it  is  most  likely  to  be  pure,  would  result  in  the 
best  possible  conditions. 

In  many  buildings,  not  only  all  of  the  air,  but  all  of  the  heat  has  been 
supplied  in  this  manner,  the  air  being  heated  sufficiently  in  passing  over  the 
coils  in  the  hot  air  chamber  to  supply  the  necessary  heat. 

The  great  advantage  in  this  system  comes  from  the  fact  that  in  order 
to  secure  a  sufficient  amount  of  heat  a  great  amount  of  fresh  air  will  have 
to  be  supplied,  and  in  this  manner  the  ventilation  must  necessarily  be  excel- 
lent during  the  cold  season.  The  amount  of  heat  supplied  to  each  room  can 
be  automatically  determined. 

There  are  four  important  objections  to  this  system.  1.  The  principal 
reason  for  rejecting  this  method  lies  in  the  fact  that  very  large  ducts  and 
outlet  surfaces  must  be  provided,  a  condition  of  things  which  is  practically 
almost  impossible  in  the  economic  arrangements  of  a  hospital.  Smaller 
ducts  and  outlets  would  not  be  practicable  owing  to  the  velocity  of  the  in- 
gress and  egress  of  air  necessary  to  give  both  heat  and  air  sufficient  to  do  the 
work.  2.  The  expense  of  maintaining  it  is  very  great.  3.  If  the  coils  are 
heated  by  steam  the  air  loses  much  of  its  invigorating  effect  because  a  great 
portion  is  actually  overheated.  4.  In  autumn  and  spring  it  is  almost  impos- 
sible to  supply  a  sufficient  amount  of  air  to  each  room  without  overheating 
it  unless  hot  water  coils  are  used  which  are  regulated  so  that  their  tempera- 
ture does  not  exceed  120°  F.  during  the  autumn  and  spring,  while  later  it  is 
raised  to  160°  F.,  and  as  the  air  passes  over  the  coils  more  slowly  a  greater 
relative  proportion  of  it  comes  in  direct  contact  with  the  coils  and  is  conse- 
quently more  thoroughly  spoiled  than  in  winter.  Moreover,  in  winter  when 
large  quantities  of  cold  air  are  blown  over  the  coils  the  surface  of  the  latter 
never  quite  reaches  the  temperature  of  the  steam  contained  within,  and  this 
in  turn  prevents  the  air  from  being  spoiled  by  overheating. 

"Whether  it  would  be  possible  to  supply  a  sufficient  amount  of  heat  in  very 


804  THE  SURGICAL  HOSPITAL 

cold  weather  if  the  hot  air  chamber  were  heated  by  hot  water  coils  at  a  tem- 
perature not  to  exceed  160*^  F.  we  cannot  state  because  so  far  as  we  have 
been  able  to  learn  this  plan  has  not  as  yet  received  a  practical  test.  That  this 
would  greatly  improve  the  quality  of  the  warm  air  there  can  be  no  doubt. 

It  would  consequently  seem  best  to  supply  only  the  fresh  air  for  ventila- 
tion heated  in  such  a  chamber  while  the  heat  for  heating  the  building  would 
be  supplied  by  direct  radiation. 

This  would  at  once  be  economically  and  hygienically  correct.  In  the  spring 
and  autumn  when  only  a  very  small  amount  of  heat  is  required  it  would  not 
be  necessary  to  use  the  steam  radiators  as  a  sufficient  amount  of  heat  could  be 
supplied  with  the  ventilation. 

In  buildings  in  which  the  air  passes  over  coils  heated  with  steam  the  at- 
mosphere is  most  depressing  during  the  months  when  little  heat  is  required, 
as  the  volume  of  fresh  air  forced  into  the  rooms  is  smaller  than  during  the 
coldest  season,  hence  a  greater  portion  comes  in  contact  with  the  overheated 
coils,  and  the  surface  of  these  coils  is  of  a  higher  temperature  than  when  a 
large  amount  of  cold  air  is  forced  over  the  coils,  hence  there  is  not  only  less 
air,  but  the  air  is  of  a  poorer  quality. 

During  the  warm  season  of  the  year  when  no  artificial  heat  is  required, 
open  windows  and  straight  corridors  are  of  the  greatest  importance,  as  well 
as  careful  grouping  whenever  several  buildings  are  constructed,  to  prevent 
obstruction  to  currents  of  air. 

In  this  again  the  higher  the  building  the  freer  will  be  the  currents  of  air, 
because  of  the  fact  that  there  must  necessarily  be  less  obstruction  from  sur- 
rounding structures  and  hence  the  natural  ventilation  must  be  better. 

Filtering  of  air.  The  best  methods  of  cleansing  air  are  the  natural  ones. 
Air  which  has  been  carried  across  a  large  body  of  water  is  practically  free 
from  impurities,  because  these  have  fallen  into  the  water.  Air  near  the  tops 
of  high  mountains  is  pure  because  impurities  fall  to  the  ground  before  they 
are  carried  to  these  great  heights.  In  tall  buildings  there  are  more  micro- 
organisms in  the  air  entering  from  without  in  the  lower  than  in  the  upper 
floors. 

For  these  reasons  it  seems  wise  to  obtain  as  large  a  piece  of  land  as  the 
means  will  permit,  in  the  highest  available  location,  and  then  construct  the 
buildings  as  near  the  center  of  such  area  as  possible.  The  higher  the  build- 
ings, the  better  will  be  the  chances  of  obtaining  good  air  for  the  greatest 
number  of  patients. 

Shrubs  and  trees  planted  between  the  building  and  the  surrounding  streets 
will  serve  to  filter  a  considerable  portion  of  the  street  dust  out  of  the  air 
before  it  reaches  the  building. 

In  forcing  air  into  a  building  for  the  purpose  of  ventilation  it  is  possible 
to  select  that  which  is  relatively  free  from  dust  and  impurities  if  the  intake 
has  its  opening  at  a  good  height  somewhere  near  the  roof  of  the  building, 
but  in  such  a  position  that  the  prevailing  winds  will  force  the  impurities  which 
come  from  the  chimneys  and  ventpipes  away  from  the  intake. 

Many  devices  have  been  instituted  for  the  purpose  of  washing  the  air  which 
is  forced  into  a  building  bj^  fans.  Streams  of  water  are  permitted  to  drip  over 
moist  gauze  or  other  substances  so  as  to  intercept  the  fine  particles  contained 
in  the  air.  This  treatment  of  the  air  has,  however,  not  yet  been  fully  and 
satisfactorily  demonstrated,  although  many  authorities  speak  well  of  it, 

A  method  which  has  been  used  frequently  by  the  government  in  some  of 
its  hospitals,  and  especially  in  its  larger  office  buildings,  is  to  heat  the  air 
above  freezing  point  and  then  pass  it  through  a  wall  of  finely  sprayed  water, 
there  being  many  of  these  small  apartments  about  eighteen  inches  square 
so  as  to  keep  the  water  from  spreading.    This  is  economical  as  the  water  can 


THE  SURGICAL  HOSPITAL  805 

be  filtered  and  used  over  and  over.  The  air  is  then  sent  into  a  drying  room 
and  from  there  into  a  space  where  a  fine  spray  gives  it  the  requisite  moisture, 
the  drying  room  being  kept  at  a  temperature  so  that  the  air  goes  out  to  the 
several  ducts  at  slightly  higher  temperature  than  that  of  the  rooms.  The  sys- 
tem has  been  found  very  satisfactory,  exceedingly  simple  and  inexpensive. 

Lighting".  Incandescent  electric  lights  are  probably  the  most  cleanly,  con- 
venient and  satisfactory  in  most  cities.  In  large  institutions  requiring  high 
pressure  steam  for  other  purposes,  such  as  running  elevators,  pumps,  laundry 
machinery,  etc.,  electricity  can  be  manufactured  at  a  reasonable  expense  for 
lighting  the  building. 

If  the  institution  is  dependent  upon  ordinary  illuminating  gas  it  is  prefer- 
able to  make  use  of  some  one  of  the  various  incandescent  mantles  in  the 
market,  as  the  quality  of  the  light  is  thus  greatly  improved,  while  for  the 
same  amount  of  light  the  amount  of  carbon  dioxide  and  smoke  are  greatly 
reduced  in  quantity,  moreover  it  is  much  easier  to  regulate  the  amount  of 
light. 

In  large  institutions  acetylene  gas  may  be  used  economically.  The  quality 
of  the  light  is  excellent  and  with  proper  care  the  amount  of  smoke  is  very 
slight. 

There  is  some  danger  of  explosion  if  the  apparatus  is  not  handled  by  a 
careful  person. 

Plumbing.  Plumbing  in  residence  and  hotel  construction  has  been  per- 
fected to  such  a  degree  that  if  the  same  care  is  employed  in  the  installment  of 
hygienic  plumbing  in  hospitals  there  is  no  reason  for  change  or  improve- 
ment, with  the  exception  that  special  facilities  are  required  for  disposing  of 
contents  of  bed-pans,  etc.  A  large  slop  sink  and  hopper,  with  a  water  seal 
which  will  at  once  dilute  any  offensive  matter  thrown  into  it,  has  been  con- 
structed recently  and  is  of  great  value.  It  is  provided  with  syphon  together 
with  a  large  plunger  which  cleanses  the  entire  contrivance  thoroughly  and  at 
once. 

Sterilizing  rooms.  Sterilizers  for  surgical  dressings,  sheets,  towels,  instru- 
ments, etc.,  are  so  perfect  as  supplied  by  many  manufacturers  that  it  is  scarcely 
necessary  to  dwell  upon  them.  Sterilizers  for  mattresses  are  not  so  satisfactory 
as  yet. 

Floors.  In  the  halls,  bathrooms,  closets,  kitchens,  operating  and  dressing 
rooms,  some  form  of  flooring  which  is  impermeable  to  moisture,  such  as  tiling 
or  glass,  has  been  generally  adopted  with  great  satisfaction,  as  it  may  be 
easily  kept  clean  and  is  attractive  in  appearance.  The  most  satisfactory  ma- 
terial is  known  as  flake  mosaic,  especially  if  this  is  made  in  the  form  of  large 
tiles.  In  the  wards  and  rooms  hardwood  floors  laid  on  the  cement  covering 
which  isolates  the  floor  from  the  lower  story,  seems  preferable.  This  should 
be  covered  by  some  dressing  impermeable  to  moisture  in  order  to  prevent 
septic  materials  from  penetrating  the  pores  of  the  wood.  A  careful  applica- 
tion of  grain  alcohol  shellac  closes  the  pores  quite  effectually. 

The  walls  should  be  covered  with  paint,  which  prevents  the  plaster  from 
becoming  filled  with  germs.  These  walls  may  be  washed  and  thus  rendered 
aseptic  after  the  rooms  have  been  occupied  by  patients  with  suppurating 
wounds. 

In  the  operating  and  dressing  rooms  walls  covered  with  tile,  marble,  glazed 
brick  or  glass  are  very  attractive,  but  they  are  in  no  way  superior  to  those 
that  have  been  carefully  covered  with  hard  enamel  paint  which  is  impervious 
and  acid  proof. 


806  THE  SURGICAL  HOSPITAL 

HOSPITAL  MANAGEMENT 

Concerning  the  internal  management  of  hospitals  there  is  much  to  be  said, 
because  at  the  present  time  no  definite  system  has  been  established,  except  in 
hospitals  under  the  control  of  sisterhoods  that  have  conducted  similar  institu- 
tions for  many  years  in  the  past. 

In  other  American  hospitals  the  management,  as  a  rule,  is  the  cause  of 
almost  unceasing  annoyance  to  every  one  connected  with  the  "vrork.  In  time, 
no  doubt,  there  will  be  developed  as  definite  systems  of  management  of  hos- 
pitals as  now  exist  in  other  departments  of  human  activity.  There  are  very 
definite  plans  for  conducting  almost  all  other  enterprises.  One  would  not 
expect  to  manage  a  railroad,  bank,  department  store,  saw,-mill,  or  any  other 
industry  unless  one  had  a  definite  knowledge  of  a  system  accoirding  to  which 
such  industries  were  commonly  conducted  with  success,  simply  because  it 
would  not  be  possible  to  compete  with  those  who  have  this  knowledge. 

It  is  quite  different  in  the  control  of  hospitals,  because  any  deficit  which 
may  occur  as  the  result  of  incompetent  or  bad  management  can  readily  be 
made  up  by  contributions  from  those  who  are  interested  in  these  institutions 
as  public  charities.  This  is  true  to  so  great  an  extent  that  one  almost  invari- 
ably finds  that  the  institutions  which  are  worst  managed  are  at  the  same  time 
most  generously  supported. 

Fortunately  many  of  the  smaller  institutions  have  but  little  outside  sup- 
port and  consequently  their  existence  depends  upon  the  ability  of  those  in 
charge  to  develop  a  reasonable  plan  of  management,  and  this  condition  must 
in  time  result  in  a  recognized  system  which  will  ultimately  become  generally 
adopted. 

For  the  management  of  smaller  hospitals  it  will  be  necessary  to  have  nurses 
educated  in  training  schools  not  only  to  do  scientific  nursing,  but  also  to  per- 
form all  the  other  duties  connected  with  the  government  of  hospitals. 

Fortunately  several  training  schools  for  nurses  have  been  organized  during 
the  past  few  years  with  this  end  in  view,  and  a  number  of  the  older  schools 
have  added  new  departments  of  instruction  in  order  to  enable  their  pupils  to 
become  more  broadly  educated,  with  a  view  of  making  them  more  thoroughly 
competent  to  manage  the  great  number  of  new  hospitals  which  are  springing 
up  in  all  parts  of  this  country. 

If  it  is  possible  to  obtain  a  trained  nurse  who  is  familiar  with  the  details 
of  the  entire  management  of  a  hospital,  it  is  usually  best  for  all  of  the  smaller 
institutions  to  vest  the  entire  management  of  the  institution  in  this  office,  i.e., 
the  superintendent  of  nurses. 

In  order  to  be  competent  to  occupy  this  position  properly,  it  will,  how- 
ever, be  necessary  for  the  occupant  not  only  to  be  an  excellent  nurse,  but 
she  must  be  a  good  housekeeper,  a  good  business  women,  must  know  how 
to  buy  supplies,  how  to  get  on  with  little  by  economizing  in  every  way.  She 
must  know  how  to  select  help  and  how  to  keep  it.  She  must  be  a  good  teacher 
in  order  to  obtain  satisfactory  work  from  the  pupil  nurses.  She  must  know 
how  to  act  promptly  and  quietly  in  case  of  emergencies.  She  must  do  all  of 
this  cheerfully,  lest  she  drive  patients  away  from  the  hospital,  and  must  con- 
sequently have  an  unlimited  amount  of  good  judgment  and  tact. 

Above  all  things  she  must  be  absolutely  reliable,  and  must  be  looked  upon 
in  that  spirit  by  every  one  connected  with  the  institution. 

One  quality  which  in  the  main  depends  upon  good  judgment  and  tact,  but 
which  is  but  rarely  found  in  persons  at  the  head  of  hospitals,  is  a  Avillingness 
to  do  what  can  be  done  under  existing  circumstances,  although  it  may  not 
quite  approach  one's  ideals,  without  grumbling  over  things  which  are  for  the 
time  being  uncontrollable. 


THE  SURGICAL  HOSPITAL  807 

A  person  who  possesses  this  quality  at  once  becomes  a  leader  and  will 
consequently  accomplish  vastly  more  in  the  end. 

Many  of  the  smaller  hospitals  owe  their  success,  if  not  their  continued 
existence,  in  a  large  measure  to  the  fact  that  they  were  able  to  secure  the 
services  of  such  a  person  for  the  leading  spirit  in  the  management  of  the 
institution. 

There  are  two  items  which  it  is  important  to  bear  in  mind  at  this  point. 

It  is  important  to  plan  the  work  so  that  this  person  has  one  entire  day  each 
week  away  from  the  institution,  and  some  time  during  each  day  for  rest  with- 
out disturbance.  One  who  has  all  of  the  most  desirable  qualities  too  often 
has  not  the  wisdom. to  take  the  necessary  rest  to  be  able  to  continue  thjs  work 
to  the  fullest  extent. 

The  other  point  is  as  regards  the  authority  of  such  a  person.  She  should 
not  be  hampered  in  any  way. 

It  is  here  that  the  harmful  effect  of  meddlesome  committees  of  women's 
auxiliary  boards  so  often  make  it  impossible  to  develop  a  desirable  system. 
In  the  few  hours  that  a  committee,  composed  of  the  most  excellent  ladies  of 
the  village  or  city,  give  to  hospital  matters  each  week  they  can  usually  per- 
petrate more  follies  than  can  be  remedied  during  the  remaining  days  by  those 
who  give  their  entire  time  and  thought  to  the  work. 

No  one  who  does  not  practically  give  all  of  his  or  her  time  to  hospital 
work  should  have  anything  to  say  concerning  the  management  of  the  insti- 
tution, aside  from  auditing  the  accounts,  and  this  should  be  done  by  an  expert 
accountant  whose  only  duty  should  consist  in  determining  the  correctness  of 
the  items. 

The  board  of  directors  should  be  divided  into  various  committees  to 
which  questions  of  importance  should  be  referred;  but  no  member  of  the 
board  should  in  any  way  interfere  in  the  conduct  of  the  institution  directly, 
because  it  is  not  at  all  likely  that  he  will  be  in  possession  at  any  time  of  suf- 
ficient data  to  make  his  interference  advantageous  to  the  institution.  Such 
interference  would  not  be  tolerated  in  any  other  business  enterprise  and  still 
it  is  only  too  common  in  the  management  of  hospitals. 

It  should  be  thoroughly  understood  that  hospitals  can  be  managed  on 
precisely  the  same  principles  that  one  applies  to  any  other  successful  business 
enterprise,  and  that  the  same  principles  will  result  in  similar  success.  This 
has  been  demonstrated  in  a  number  of  the  most  useful  hospitals  in  this  coun- 
try, and  only  when  this  desideratum  has  become  generally  accepted  and  put 
into  practice  can  we  expect  the  greatest  possible  amount  of  benefit  to  come 
from  these  institutions. 

All  persons  performing  work  in  the  hospital  should  be  properly  paid  for 
their  services,  otherwise  the  service  is  certain  to  be  very  inefficient  and  the 
institution  will  be  compelled  to  feed  and  house  an  army  of  incompetents  who 
would  not  even  be  able  to  earn  their  board  and  lodging  elsewhere. 

The  above  tenet  will  make  it  proper  to  expect  good  work  from  every 
one  employed,  and  any  one  who  fails  to  do  his  share  of  the  work  may  be  dis- 
missed with  justice  to  himself  and  benefit  to  the  hospital. 

Pupil  nurses  receive  their  tuition  in  the  form  of  lectures,  class  work,  reci- 
tations, laboratory  work  and  bedside  instruction,  which  should  pay  for  their 
services  in  part  or  in  Avhole.  In  the  larger  hospitals  this  is  also  true  of  the 
members   of  the  resident  medical  and  surgical  staff. 

The  number  of  assistants,  pupil  nurses  and  servants  necessary  depends  en- 
tirely upon  the  size  of  the  hospital  and  the  character  of  the  work  performed. 

In  an  institution  of  less  than  thirty  beds  it  will  not  be  necessary  to  have 
a  matron  or  housekeeper.  In  a  larger  hospital  this  will  be  necessary,  but  this 
position  should  be  under  that  of  superintendent  of  nurses.    It  is,  however,  a 


808  THE  SURGICAL  HOSPITAL 

great  advantage  to  the  institution  to  have  a  matron  who  is  also  a  graduate 
of  a  training  school  for  nurses,  because  she  will  be  much  better  able  to  com- 
prehend the  demands  upon  her  department. 

The  other  servants,  such  as  cook,  chamber-maids,  laundress,  janitor  as 
well  as  the  number  of  pupil  nurses,  will  depend  upon  the  number  of  beds 

There  are  many  other  items  which  might  be  discussed  in  this  connection 
but  what  has  been  said  above  will  suffice  to  make  clear  the  most  important 
principles  involved  m  the  organization  and  management  of  a  hospital 

Supplies.  In  purchasing  hospital  furniture  it  is  important  to  combine 
utility  and  durability  with  attractiveness,  at  the  same  time  securing  furni- 
ture which  can  easily  be  kept  clean. 

For  a  number  of  years  hospital  authorities  have  neglected  to  pay  sufficient 
attention  to  the  element  of  attractiveness  so  that  the  beds,  for  instance  remind 
one  more  of  cots  m  a  penitentiary  than  of  beds  for  the  use  of  sick  human 
beings  who  need  cheerful  surroundings. 

It  is  now  possible  to  secure  attractive  hospital  beds  which  are  strong 
easily  cared  for  and  easily  kept  clean.  ^i^iuiig, 

_      The  bed  for  surgical  cases  should  be  high  so  that  the  top  of  the  mattress 
IS  seventy-five  cm.  from  the  floor.     This  makes  the  work  very  much  eSLr  fo? 
the  nurses.    The  beds  should  be  so  built  that  either  the  uppe/or  the  lower  end 
can  readi  y  be  elevated     It  is  important  to  secure  good  springs  for  the  bed 
The  other  articles  of  furniture,  like  bedside  tables,  wash  stands,  etc.,  should 

be  ke  T  deTn  '^         ^''^'^^'''  ^''"^'"''  ^"""^  ^"^  ^""'^^  *^^*  ^^^^  can  readily 

The  utensils  furnished  by  hospital  supply  houses  are  so  convenient  and  so 
well  made  that  it  is  not  necessary  to  describe  them  especially 

There  should  be  a  sterilizer  on  each  floor  so  that  all  utensils  may  be  steril- 
ized regularly  after  they  have  been  used. 


INDEX 


Abdomen,  general  surgery  of  the,  227. 
Abdominal  incisions,  228. 

Abdominal     wall,     abscesses     in     the,     treat- 
ment, 402. 
fibro-sarcoma,  402. 
tumors  of  the,  lipoma,  402. 
Abscess,  alveolar,  139. 
mediastinal,  203. 
of  liver,  530. 
of  the  lung,  technique,  199. 

danger   of  lung  collapse   and  its  preven- 
tion, 199. 
physical  signs,  199. 
of  seminal  vesicles,  605. 
perinephritic,   550. 
Actinomycosis,    curative    value    of  potassium 
iodide,  and  the  dosage,  purity  of  the 
drug,  198. 
positive  sign,  the,  198. 
Adenoids,  post-nasal,  133. 

breathing  exercises  in,  145. 
Alveolar  abscess,  139. 

Alexander    operation    for    shortening    of    the 
round  ligaments,  652. 
prognosis  of,  653. 
Amputations,  727. 

Anatomic     and    functional    results     of    frac- 
tures,  661. 
Anemia,  splenic,  380. 
pernicious,  384. 
splenomegaly  without,  382. 
syphilitic     splenomegaly     accompanied     by 
secondary,  382. 
Anesthesia,  chloroform  followed  by  ether,  63. 
danger  signals,  63. 
general,  62. 
intravenous,  68. 
local,   66. 

a  ready  freezing  mixture,  70. 
ethyl  chloride,  70. 
Schleich's  infiltration  method,  67. 
morphine  and  atropin  in,  64. 
nitrous  oxide  gas,  contraindications,  64. 
organic  heart  lesions  in,  62. 
preference  given  to  ether,  64. 
rectal,  apparatus,  73. 
advantages  claimed,  71. 
method  of  application,  72. 
regional,  67. 

endoneural  method,  68. 
intravenous  method,   68. 
perineural  method,  68. 
spinal,  69. 
Angioma,  Wyeth  method  of  treatment,  146. 
Ankylosis  of  jaw,  140. 


Ankle  joint,  resection  of,  709. 
Antiseptic  dressings  for  infections,  693. 

solution  for  infections,  694. 
Antrum  of  Highmore,  131. 
Anuria,  post  operative,  555. 
Appendicitis,    absorption    of   poisonous    intes- 
tinal products  in,  259. 
acute,  complicating  strangulated  hernia  in, 
276, 
perforative,  238. 

conclusions  on  treatment,  254. 
considerations   of  treatment,  239. 
gastric  lavage  imperative,  243. 
return  to  diet,  247. 
typical  history,  238. 
with  secondary  infection  of  the  pelvic  or- 
gans   in    the    female,    complications 
in,  268. 
after  treatment  in,  273. 
drainage  in,  273. 

gangrenous,  incision  for,  262. 
treatment  of,  263. 
diagnosis  of,  262. 
perforative  or  gangrenous  with  peritonitis 
and  abscess,  258. 
without  abscess,  258. 
without  per-foration,  257. 
with  carcinoma,  279. 
chronic,   review  of  five  hundred   and   forty 
cases,  256. 
recurrent,  231. 

abdominal  wound,  232. 

adhesions    (peritoneal),    prevention   of, 

233. 
atypical   conditions,    important   conclu- 
sions, 237. 
floating   kidney   in,   278. 
ligatures  closing  the  abdominal  wound, 

234. 
pathological  appearance  of,  235. 
prognosis  technique,  231. 
typical  instance,  231. 
complications  of,  276. 

diagnosis  dependent  upon  a  careful  physi- 
cal examination,  249. 
diffuse  peritonitis  in,  279. 
immediate  operation,   the   determining  con- 
dition of  the,  253. 
in  children,  diaarnostic  error,  274. 
in  old  people,  276. 
local  infection,  time  limit  of,  252. 
localization  of  the  disease,  252. 
nature's   protective  influences,   253. 
pregnancy  in,  279. 

review  of  an  extensive  series  of  cases,  254. 
thrombo-phlebitis  in,  278. 
to  reduce  the  mortality  from,  248. 


809 


810 


INDEX 


Appendix,  anatomical  surroundings  of,  240. 

condition  after  an  acute  attack,  252. 

drainage  of,  25U. 

guides  to  tlie,  233. 

removing  the,  233. 
Arthroplasty,  718. 

B 

Bartholin's  glands,  cysts  of,  658. 
Bladder,  exstrophy  of,  568. 

tumors  of,  593. 
Blood,  atypical  cells,  42. 
color  index,  40. 

erythrocytes,  counting  of,  39. 
differential  count,  40,  42. 
films,  Wright  stain,  40. 
Jenner  's  stain,  41. 
Ehrlich  tricolor  mixture,  41. 
leucocytes,  counting  of,  39. 
normal  differential  count,  55. 
pathological  conditions  of,  43. 
staining  of  blood-films,  40. 
supply,  importance  of  safeguarding,  22. 
technique  for  microscopical  examination  of, 

38. 
transfusion,  734. 

indications  for,  734. 
technique  of,  737. 
vessels,    injuries    to    the    walls    of    during 
operations,  81. 
repair  of,  82. 
Bone  graft,  fixation  of  fractures  by,  676. 
Bone  grafting,  important  features  of  the  op- 
eration, 688. 
non-malignant  tumors  of,  724. 
transplantation,  indications  for,  688. 
osteogenesis  of,  687. 
Bones,  crushing  injuries  to,  721. 
Bowel  surgery,  general  principles  in,  291. 
Brain,  abscess  of  the,  1 15. 
tumors  of  the,  113. 

decompression   operation,   115. 
Branchial  cysts,  152. 

Breast,  carcinoma  of  the  skin  of,  recurrence, 
214. 
epithelioma  of,  220. 
milk  fistula,  221. 
sarcoma  of,  220. 
tuberculosis  of,  221. 
tumors,  205. 

a  dangerous  custom,  206. 
age  incidence,  207. 
dangers  of  even  simple  growths,  205. 
lines  of  incision  and  technique,  208. 
operative  principles,  208. 
physical  signs,  205. 
Bronchi,  foreign  bodies  lodged  in,  225. 
Bunion,  732. 


Cachexia,  due  to  malignant  growths,  23. 

danger  in  preliminary  treatment,  24. 
Calculus,  renal,  564. 
Cancer  en  cuirasse,  214. 

of  the  pyloric  end  of  the  stomach,  radical 
operation  for  the  cure  of,  486. 
Carbuncle,  696. 


Carcinoma    (disseminated   lenticulate)    of  the 
skin  of  the  breast,  214. 
of  labia  majora,  minora,  and  clitoris,   656. 
of  the  lower  jaw,  138. 

of  the  lymphatic  glands  of   the  neck,   173. 
of  the  pyloric  end   of   the   stomach,   opera- 
tive detail,  489. 
of  the  rectum,  the  combined  abdominal  and 

perineal  method  of  removing,  401. 
of  the  stomach,  determination  of  operative     « 
intervention,  488.  u 

and  gastric  ulcer,  480.  1 

early  diagnosis,  importance  of,  480. 
indications  for  operations,  482. 
non-oi^erative  cases,  486. 
preparatory  treatment,  482. 
some  misleading  statements,  487. 
technique,  483. 
typical  case,   diagnosis,   482. 
of  the  uterus,  prognosis  of,  639. 

abdominal  vs.  vaginal  hysterectomy,  628. 

after  care  of,  633. 

dangers    of    diagnostic   sections    and    cu- 

rettement,  630. 
importance  of  early  diagnosis,  628. 
operative  technique,  630. 
radiotherapy  of,  633. 
Cardio-spasm,  diagnosis,  430. 

treatment,   Sippy  dilatation  method,  431. 
Cartilage,  technique  of  transplanting,  134. 
Castration,  605. 
Cast,  Unna's  paste,  699. 
Catgut,  chromicized  preparation  of,   53.. 
iodine,  55. 

method  of  prepari'ng  and  preserving,  52. 
tanned,  Ssobelew  method,  56. 
Willard  Bartlett  method  of  preparing,  55. 
Cathartics,  mode  of  action  of,  282. 

the    effect    of    the    introduction    into    the 
stomach,  241. 
Cecum,  excision  of,  typical  history,  291. 
after-treatment,  301. 
conservative   treatment,   293. 
diagnosis,  292. 
Murphy  button  in,  299. 
preparatory   treatment,   295. 
sutures,  rules  governing,   300. 
technique  of  operation,  295. 
the  suture  method,  298. 
Cerebral   abscess,  115. 

localization,  109. 
Cervical      atresia     producing      dysmenorrhea, 
659. 
erosion,  644. 
laceration,  644. 

operative  technique  of,  646. 
preparatory  treatment  of,  646. 
usual  history  of,  645. 
Chest,  gunshot  and  stab  wounds  of,  200. 
surgery  of  the,  185. 
tumors  of,  203. 

wall,  mobilization  of,  Friedrich  's  method  by 
means  of  total  removal  of  bone  with 
preservation      of      pleura      costalis, 
technique,  192. 
anesthesia,  little  general  anesthesia  re-  . 

quired,  193. 
heart-effect,  193. 


INDEX 


811 


Cholecystitis,  509. 
Cholecystectomy,   519. 
Cholecystenterostomy,  525. 

after-treatment,  525. 
Cholecystotomy,  514. 
Choledochotomy,  522. 
Cholelithiasis,  509. 
Cholemia,  treatment  of,  512. 
Cleft  palate,  126. 

Brown  operation,  129. 

effect  of  training  upon  speech,   127. 

fistula  following  operation,  1.30. 

hemorrhage,  129. 

involvement  of  hard  palate,  128. 

Lane 's  operation,  130. 

sutures,  129. 

technique  of  operation,  127. 

time    of    operating,     differing    opinion    as 
to,  126. 
Clinical  history  form,  31. 
Colon,  resection  of  the,  305. 
Gibson  method,  305. 
after-treatment,   306. 
Colostomy,  inguinal,  306. 

alternative  procedure,  310. 
after-treatment,  309. 
technique,  306. 
Common  duct  obstruction,   509. 
Compound  fractures,  679. 
Congenital  dislocation  of  the  hip,  685. 

pathology,   signs    and   symptoms,    diagnosis 
and  treatment,  685. 
Constipation,   surgical   treatment   for.   Lane  'a 

technique,   311. 
Crushed  wounds,  tincture  of  iodine  in,  49. 
Cystic  duct,  obstruction  of,  508. 

kidney,  556. 
Cyst,  ovarian  with  twisted  pedicle,  613. 
Cystoscopy,  540. 
Cystotomy,  590. 
Cysts,  branchial,  152. 

dermoid  of  the  ovary,  613. 

fluid  of,  613. 

ovarian,   609. 

of  Bartholin's  glands,  treatment  of,  658. 

pancreatic,  392. 

sublingual,  143. 

thyroglossal,  153. 


D 


Decapsulizatiou   of  the  kidney,   562. 
Decompression  operation,  115. 
Dentigerous  cysts  of  the  jaw,  137. 
Dermoid  cysts  of  the  ovary,  613. 
Diabetic  gangrene,  731. 
Dilatation  of  the  stomach,  461. 
Disinfection  of  silk,  silkworm  gut,  etc.,  52. 
Drainage,  58. 

cigarette,  58. 
Dressings,   antiseptic,   for  infections,   693. 

disinfection  of,  57. 
Duodenum,  constriction  of,  528. 
Dysmenorrhea   due   to   atresia   of   the   cervix, 
659. 


E 


Elbow,  tuberculosis  of,  701. 
Elongated  cer\dx,  removal  of,  642. 
Emphysema,  excision  of  costal  cartilages  for 

relief  of,  224. 
Empyema,   after-treatment,   187. 
anesthesia  technique,  186. 
Beck's  bismuth  paste,  186,  188. 
chronic,    conditions    favoring    this    disease, 

190. 
conclusions  and  further  details,  189. 
danger  of  supervening  tuberculosis,  188. 
drainage,  continuance  of,  188. 
drainage  and  non-irrigation,  186. 
fistula   and    abscesses    following    operations 

for,  188. 
glycerine-formalin  solution  in,  185. 
illustrative  case,  189. 
of  frontal  sinus,  132. 
of  antrum  of  Highmore,  131. 

use  of  Beck's  bismuth  paste  in,  131. 
signs  and  symptoms,  185. 
technique,  190. 
Environment  in  operating,  29. 
Epididymectomy,   604. 
Epiphyseal  fractures,  684. 
Epilepsy,  idiopathic,  112. 

trefthining  for  the  cure  of,  111. 
Epistaxis,  136. 

chronic  recurrent,  136. 
Epithelioma  of  the  face,  147. 
Erosion  of  the  cervix,  644. 
Esophagitis,  toxic,   406. 

treatment,  407. 
Esophagotomy,  technique,   182. 
Esophagus,   cysts,  papillomata,  myomata  and 
earcinomata  of  the,  415. 
diverticula  of  the,  diagnosis,  427. 

treatment,  428. 
external  injuries  of  the,  treatment,  416. 
foreign  bodies  in  the,  symptoms,  416. 
diagnosis,  417. 
treatment,  417. 
foreign  bodies  of,  extraction  by  the  aid  of 

the  esophagoscope,  417. 
foreign  bodies  of   the,   esopjhagotomy,   418. 

gastrotomy,  419. 
inflammatory  processes  of  the,  406. 
injuries  of  the,  internal  source,  415. 
idiopathic   dilatation   of  the,   symptoms   of, 
429. 
etiology,  429. 
new  growths  of  the,  symptoms,  408. 
diagnosis,  410. 
dilatation  of,  411. 
prognosi^,  411. 
treatment,  411. 
esophagostomy,  411. 
gastrostomy,   413. 
phlegmon  of  the,  407. 
resection   of  the,   413. 
surgery  of  the,  radioscopy,  406. 
esonha£?oscopy,   406. 
methods   of  examination,  40.5. 
stricture  of  the,  symptoms,  420. 
Abbe's  string  cutting  method,  426. 
Billroth 's  method,  426. 


812 


IxXDEX 


diagnosis,  422. 
dilatable  strictures,  424. 
nou-dilatable   strictures,  424. 
the  Oehsuer  method,  424. 
treatment,  422. 
use  of  the  X-ray,  422. 
ulcer  of  the,  407.' 
Ethmoid  cells,  132. 

technique   of  operation,   132. 
Examination  of  patient,  17. 
Exstrophy  of  the  bladder,  568. 

plastic  operations  for  closing  the,  573. 
Exophthalmic  goitre,  156. 
Extremities,  septic  infection  of,  typical  case 
692.  ' 

crushing  injuries  of  the,  719. 
electric  light  treatment  in,  695. 


Facial  nerve,  resections  of  portions  of,  for  the 

relief  of  neuralgia,  122. 
Feces,   examination  of,  acidity,   452. 
color,  451. 
gallstones,  452. 
odor,  pus,  452. 
Schmidt  test  diet,  452. 
test  for  bile  pigments,  452. 
tests   for   pancreatic   function,  452. 
test  for  pancreatic  ferments,  452. 
microscopical   examination   of,   45. 
Female  pelvis,  609. 

Femur,  non-union  of  the  neck  of  the,  684. 
Fissure  in  ano,  technique,  396. 
Fistula  in  ano,  technique,  397. 
after-treatment,  398. 
intestinal,  322. 
permanent  ureteral,  567. 
•recto-vaginal,   658. 
vesico-vaginal,  657. 
Floating  kidney,  557. 
Foreign  bodies  in  the  nose,  136. 

lodged  in  the  bronchi,  225. 
Fowler  position,  the,  245. 
Fracture  of  the  acromion  process,  683. 
of  the  outer  end  of  the  clavicle,  683. 
of  the  olecranon,  technique  of  repair,  683. 
of  the  patella,  case  history  with  technique 

of  repair,  679. 
of  the  olecranon,  682. 
of  the  lower  jaw,  136. 
of  the  nose,  133. 
Fractures,  compound,  679. 
epiphyseal,  684. 
fixation  of,  664,  676. 
functional  and  anatomic  results  of,  661. 
in  children,  679. 
malunited,  678. 
operative   treatment  of,   661. 
removal  of  plates  from  same,  671. 
technique.  667. 
through  the  epiphyses,  684. 
ununited,  677. 
Frontal  sinus,  132. 


G 


Gall  bladder,  .501. 
complications,  502. 


contraindications  to  operations,  511 
disease,  sjTuptoms  and  signs  of,  503 
diverticulum  of,  506. 
operations,   512. 
stone  colic,  504. 
Gangrene,   diabetic,   731. 

point  of  amputation  in  cases  of   731 
senile,  729.  ' 

Gasserian  ganglion,  removal  of,  119. 
Gastric  lavage,  technique,  244. 
retention,   intermittent,  439. 
ulcer,  chronic,  hypertrophy  of  gastric  mus- 
cles, 464. 
chronic,   secretion  of  mucus,  464 

treatment,  464. 
diagnosis,    facts    elicited    by    laboratory 
examination,  454. 
facts  elicited  upon  examination,  454 
facts  determined  from  history,  453 
etiology,  436. 

excision  of,  technique,  474. 
frequency  of  occurence,  438. 
Ecutgen-ray  findings,   459. 
Gastro-enterostomy,   after-treatment    474 
and    entero-enterostomy    with    the    McGraw 

elastic  ligature,  technique,  475 
closing  of  the  pylorus,  471. 
feeding,  474. 
incision,  467. 

preparatory  treatment,  467. 
Gastroptosis,  after-treatment,  500. 
operative   treatment,  498. 
Rovsing's  operation,  500. 
treatment,  498. 
Gastrostomy,  technique,  419. 
Gaucher 's  disease,  381. 
Genito-urinary   tract,   surgery   of,   537. 
Glands  of  neck,  tuberculous,  166. 
Goitre,   apparent   cause,   153. 
characteristics,  155. 
diagnosis,  155. 
directions    to    patient    following    operation 

for,    164. 
exophthalmic  anesthesia  in,  160. 
after-treatment,   164. 
blood  analysis  in,  157. 
characteristic     svmpfoms,     sum^marv     of 
156.  •  ' 

conclusions,  164. 

mortality  in,   163.  \ 

recent  advancements,  163. 
technique,  161. 

value  of  early  diagnosis,  157. 
youthful  patients,  158. 
hygiene  and  internal  medication,  156. 
Gunshot  and  stab  wounds  of  the  chest,  hemor- 
rhage, 200. 
do  not  probe:  apply  chest  splint,  201. 
value  of  the  chest  splint,  201. 


Hands,  preparation  of,  50. 
Hare  lip,  best  time  for  operating  and   prep- 
aration, 125. 

technique   of  operation,   125. 

double,  126. 


INDEX 


813 


Harris  segregator,  537. 
Head,  surgery  of,  97. 

tetanus  antitoxin  in,  98. 
Heart,  wounds   of,  223. 
Hemolytic  jaundice,  381. 
Hemorrliage,  chronic  sub-dural,   104. 

control  of,  27. 
Hemorrhoids,  393. 
after-treatment,  395. 
diagnosis,  393. 
ligature  method,  395. 
operative  technique,   393. 
radical   operation,   396. 
treatment,  393. 
Hemostasis,  78. 

application  of  sutures,   80. 
crushing  and  apjilication  of  heat,  79. 
external  pressure,  81. 
position  of  extremities,  81. 
searing  of  bleeding  surfaces,  80. 
torsion  of  blood  vessels  for,  79. 
Hernia,  diaphragmatic,  377. 
etiology  of,   332. 
femoral,  after-treatment,  347. 
clinical  case,  343. 
differential  diagnosis,  343. 
etiology,  343. 
operative  steps,  344. 
general  treatment,  333. 
general  considerations,  330. 
hernial  sac,  the,  330. 
intra-abdominal,  378. 
in  old  men,  368. 
in  children,  conclusions,  367. 

predisposing  conditions  to  overcome,  363. 
conditions     favoring     spontaneous     cure, 

363. 
technique  of  operation,  363. 
indications  for  operation,  362. 
etiology,  362. 

differential  diagnosis,  362. 
example,  362. 
inguinal,   differential   diagnosis,   336. 
etiology,  337. 

indications  for  operation,  337. 
operative  technique,  338. 
prognosis,  342. 

preparation  for  operation,  337. 
typical  case,  335. 
linea  alba,  operative  technique,  359. 
differential   diagnosis,   359. 
operation,  indications  for,  359. 
operative  technique,  360. 
typical  case,  359. 
pre- operative  management,  333. 
sac,  varied  contents  of  the,  331. 
strangulated,  370. 
in  children,  366. 
umbilical,  after-treatment,  352. 
etiology,  347. 
example,  347. 

indications   for   oneration,   348. 
Mayo  technique,  348. 
remedial  measures.  348. 
variation   of  incision,   352. 
ventral,   following  abdominal   surgery,   353. 
etiology,  353. 
indications   for   operation,  354, 


operative  technique,  356. 
principles  of  cure,  357. 
Hip,  congenital  dislocation  of,  685. 

joint  tuberculosis,  698. 
Hodgkin's  disease,  172. 
Hospital  management,  824. 

the  surgical,  805. 
Hydatids  of  liver,  532. 

diagnosis,  treatment,  532. 
Hvdrocele,  586. 
Hydrothorax,  202. 
Hyjjeracidity,  461. 
Hypospadias,  581. 
Hysterectomy,  abdominal,   615. 

combined  vaginal  and  abdominal,  640. 

vaginal,  628. 

for  non-malignant  conditions,  640. 


Incisions,  abdominal,  228. 
general  rules  regarding,   74. 
nine  rules  of  guidance,  74. 
Sanger  method,  78. 
Infancy  in  regard  to  operations,  21. 
Infection,  catgut,  54. 
of  the  kidney,  544. 
of  ethmoid  cells,  132. 
Infections,  antisej»tic  solution  for,  694. 
Ingrown  toe-nail,   732. 

Injuries,   crushing,   of   the   extremities,   treat- 
ment of,  719. 
Instruments,  surgical,  87. 
disinfection  of,  52. 

surgical,   forceps,  Koeher   and  Kelly  hemo- 
states,  88. 
Allis'  anastomosis,  88. 
Henrotin's  vulsellum,  94. 
Linnartz  's   anastomotic,  93. 
prostatic,  Ferguson's,  92. 
prostatic  lobe.  Young's,  93. 
Stone's  tissue,  89. 
tongue,  Senn's,  93. 
adenoid  curette,  Gottstein  's,  90. 
catheter,  self -retaining,  92. 
head-lamp,  90. 
hemorrhoid,  94. 
nail  cleaners.  92. 
retractors,  91. 
scissors,  89. 

scoop,  gall  stone.  Mayo  Eobson's,  89. 
shears,  Shoemaker's  rib,  89. 
soldering  iron,  90. 
sounds,  urethral.  La  Fort's,  91. 
spoon,  Thomas  prostatic,  92. 
syrinsres,  Luer  's  all-glass,  94. 
tonsillotome,  Moses  Gunn,  90. 
trocar,  Emmet's,  91. 
Whitehead's  mouth  gag,  90. 
Intestine,     acute    mechanical    obstruction     of 
the,  326. 
operative  technique,   327. 
Intestinal   fistula,   causes   and  incidence,   322. 
operative  technique,  322. 
spontaneous  cure  in,  322. 
Intestinal     obstruction     following     abdominal 
operations,  328. 


814 


INDEX 


I 


Intubation,  178. 

aecompauying   difficulties   and   their   correc- 
tion,  179. 
te<;hnique,   179. 
Intussusception,  after-treatment,   325. 

typical  case,  324. 
Iodine  and  benzine,  49. 
lodoform-glvcerine    injection    of    tuberculous 

joints,  713. 
Irrigation,  59. 


Jaundice,  hemolvtie,  381. 

Jaw,  excision  of  the  upper,  technique  of  op- 
eration, 140. 
Joint,   sacro-iliac,  tuberculosis  of,  711. 
Joints,   large,   tuberculosis  of,    707. 

tuberculous,      iodoform-glycerine      injec- 
tions of,  713. 
tuberculosis  of,  707. 

K 

Kidney  cystic,  556. 

decapsulization  of,  562. 
infection  of,  544. 
movable,  557. 

Billington   operation,   561. 
plastic  operations  on  the  pelvis  of  the,  561. 
resection  of,  563. 
tuberculosis  of,  551. 


Laceration   of   the  cervix,   symptoms   of,   644. 

of  the  perineum,  operative  technique  of,  648. 
Laryngotomy,  180. 
Laryngectomy,  180. 

technique,   181. 
Laxatives  before  operations,  20. 
Ligation  of  the  middle  meningeal  artery,  103. 
Ligature  material,  84. 
Lignous  infiltration  of  the  neck,  175. 
Lipoma  of  neck,  diffuse  dissecting,  174. 
Lip,  tumors  of  the.  angioma,  146. 

epithelioma  of,  147. 
Liver,  abscess  of,  530. 

hydatids  of,  532. 

injuries  of,  533. 

symptoms,  prognosis,   treatment,   531. 
Lung,  abscess  of,  199. 

Lymphatic  glands   (cervical"),  enlargement  of, 
complicated  by  leukemia,  173. 

of  neck,  carcinoma  of,  173. 
Lympho-sareoma  of  the  neck,  173. 

M 

Malarial  parasites,  41. 
Malarial  splenomegaly.  382. 
Malunited  fractures.  661. 

technique  of  repair.  667. 
Mammary    gland,    infections    of,    methods    of 
production.  203. 
rest  and  methods  of  prevention,  204. 
technique,  204. 
Mastitis,  chronic,  204. 


Mastoid  cells,  abscess  of  the,  117. 

operation,  technique,   117. 
in  chronic  cases,  118. 
use  of  Beck's  bismuth  paste  in,  119. 
McGraw  elastic  ligature,  475. 
Mechanical   obstruction    of   the   intestine,   ef- 
fect of  cathartics  in,  283. 
Mediastinal  abscess,  203. 
Mental  impressions,  29. 
Metal  clips,  84. 
Military,    amputations,   766. 

cranial   injuries,   769. 

face   injuries,   775. 

foreign  bodies,  764. 

general  care  of  sick  and  wounded,  753. 

gunshot  fractures,  784. 

gunshot  wounds  of  chest,  778. 

nerve  injuries,  786. 

projectiles,  748. 

treatment  of  wounds,  757. 

wounds  of  the  abdomen,  780. 
Mixed  infection  in  tuberculous  bone  and  joint 

disease,  712. 
Modern  military  surgery,  745. 
Mother,    protection    of    in    the    after-care    of 

infants,   21. 
Movable  kidney,  etiology,   557. 

Billington  operation,  561. 

complications  of,  561. 
Mvdl  's    operation    for   exstrophy   of    bladder, 

569. 
Myomectomy,  621. 

N 

Nasal  polypi,  133. 

Xares,  contracted,  133. 

Xeek,  crushing  injuries  of,   152. 

cysts  of,  152. 

incision,  lines  of,  151. 

surgery  of  the,  151. 

traumatism  of,   151. 
Nephrectomy,  552. 

anuria,  postoperative,  555. 
Nephrotomy,  .547. 
Nephrorrhaphy,   557. 
Nephrolithiasis,  564. 
Nerves,  alcoholic  injection  of,  122. 

inferior  dental  and  lingual  resection  of,  123. 

infraorbital,  resection  of,  124. 

supraorbital,  resection  of,  125. 

suture,  703. 

transplantation   of,   705. 
Non-union  of  the  neck  of  the  femur,  684. 
Nose,  foreign  bodies  in  the,  136. 

fracture  of,  133. 
Nussbaum   operation   for   varicose   ulcer,   701. 

O 

Obesity  of  patients,  22. 

Obstruction,   acute,   due   to  kinking  of   intes- 
tines, 328. 
errors  in  post-operative  treatment,  330. 
of  the  intestine,  acute,  due  to  constricting 
bands  of  adhesions,  328. 
mechanical  operative  technique,  327. 
of  common  duct,  509. 
of  the  cystic  duct,  518. 


INDEX 


815 


Old  age  in  surgery,  19. 
Operating  room,  tlie,  60. 
Operation,  field  of,  48. 

speed  in,  24. 

surface  preparation,  48. 

use  of  antiseptic  fluids,  48. 
Operations  in  two  or  more  stages,  20. 
Operative    devices    for   fixation   of    fractures, 
676. 

treatment  of  osteomyelitis,  689. 
Operations  for  the  relief  of  fractures,  661. 

old  age  in  regard  to,  19. 

the  personal  element  of  risk  in,  18. 

traumatism  in,  26. 
Osteomyelitis,  689. 

chronica,  operative  technique  of,  690. 

of  the  lower  jaw,  139. 

technique    in    acute    cases,    technique    in 
chronic  cases,  139,  691. 

operative  treatment,  689. 
Ovarian  cysts,  609. 

technique  of  removal,  613. 

with  twisted  pedicle,   613. 

complications  of,  615. 
Ovaries,  transplantation  of  with  technique  of 

operation,  627. 
Ovarian  tumors,  609. 


Pancreatic  cysts,  392. 
Pancreatitis,  acute,  symptoms,  391. 
chronic,  treatment  of,  390. 
conclusions,  392. 
diagnosis,  389. 
etiology,  388. 

acute,  surgical  treatment  of,  391. 
symptoms,  390. 
Parotid  gland,  excision  of,  141. 
Patient,  general  examination  of,  17. 

preparation  of,  46. 
Pelvis,  female,  609. 
Penis,  amputation  of,  574. 
Perforated   gastric    or   duodenal   ulcer,   treat- 
ment, 462. 
Pericardial    adhesions,    mobilizing    the    chest 
wall  for  relief  of,  221. 
effusion,  222. 
suppuration,  222. 
Perinephritic  abscess,  550. 
Perineal  laceration,   after  treatment   of,   650. 

concomitant  hemorrhoids,  650. 
Perineum,  laceration  of,   648. 
Peritonitis,  conclusions,  284. 

cathartics  in  the  treatment  of,  280. 

to  be  avoided  in,  30. 
diffuse,  279. 

prevention  and  inhibition  of,  279. 
tubercular,  a  typical  case,  286. 

medical  vs.  surgical  treatment,  287. 
resume  of  cases,  289. 
treatment  of,  287. 
Pernicious  anemia,  384. 
Phosphorus  poisoning,  139. 
Pneumothorax,     artificial,     ability     to     work, 
duration  of  treatment,  198. 
apparatus,  technique,  194. 


complications    and    dangers,    air    or    gas 

embolism,  195. 
definition,  193. 
emphysema,      over-inflation,      pneumonia, 

prognosis,  196,  197. 
indications,   contraindications,   194. 
the    Fell    bellows,    the    Sauerbruch    cabinet 
and  other  methods,  201. 
Preparations,  general,  46. 

of  the  patient  for  operation,  31. 
Preparatory       treatment,       prolonged,       con- 
demned, 47. 
Pressure  necrosis,  54. 

Prolapse  of  the  uterus,  prognosis  of,  642. 
Prostatectomy,  598. 
Prostatotomy,  603. 
Pyelotomy,  563. 
Pylorus,  resection  of  the,  486. 
Pyosalpinx,  diagnosis  of,  622. 
clinical  example  of,  622. 
pathology  of,  623. 
after  treatment  of,  626. 
medical  treatment  of,  623. 
operative  treatment  of,  625. 

E 

Eadiotherapy    in    carcinoma    of    the    uterus, 

628. 
Ranula,  143. 

Eectum,  carcinoma  in  upper  portion  of,  tech- 
nique, 319. 
carcinoma  of  the,  399. 
prognosis  in,  401. 
technique,  400. 
prolapse  of  the,  severe  forms,  399. 
technique,  398. 
Eeeto-vaginal  fistula,  658. 
Eemoval  of  elongated  cervix,  642. 
Eenal  calculus,  564. 
Eesection  of  the  pylorus,  486. 
Eibs,  tuberculosis  of,  198. 
Eubber  gloves,  51. 
Eupture  of  the  urethra,  596. 

S 

Sacro-iliac  joint,  tuberculosis  of,  711. 
Saddle  nose,  134. 

technique  of  transplanting  cartilage,  134. 
use  of  paraffin,  134. 
Saphenous  veins,  excision  of,  698. 
Sarcoma  of  the  lower  jaw,  138. 
Scalp,  injuries  to  the,  97. 
Scalp,  non-traumatic  infection  of  the,  101. 
tumors  of  the  sebaceous  cysts,  99. 
lipomati,   100. 
warts  and  moles,  100. 
nevus,  100. 

sarcoma  and  carcinoma,  101. 
tuberculosis  of  the,  101. 
Seminal  vesicles,  abscess  of,  605. 
Septic  infection  of   deep  tissues  in  the  neck, 
175. 
of  the  extremities,  692. 
Septum,  deflected,  134. 
Shock,  influences  affecting,  29, 


816 


INDEX 


Shortening   of   the   round   ligaments,   Alexan- 
der operation,  652. 
Shoulder,   tuberculosis   of,    711. 
Sinus  thrombosis,  infective,  119. 
Skin  grafting,  701. 

Skull,  closure  of  bonv  defects  in  the,  109. 
compound  fractures  of,  105. 
fractures  of  the  base,  106. 
injuries   of   the,   101. 

simple  depressed  fractures,  105. 
chronic   subdural  hemorrhage,  104. 
middle  meningeal  artery,  ligation  in,  103. 
primary   tumors  of,   107. 
punctured  wounds  of,   106. 
tumors  of  the,  107. 
tuberculosis  of  the,  107. 
Small   intestine,    resection   of   the,    technique. 
301. 
Connell  method,  30-1. 
steps  of  the  operation,  304. 
Splenectomy,   diagnosis,  387. 
Spleen,  378. 

wandering,  operation,  383. 
Splenic  anemia,  380. 
Splenitis,  chronic,  383. 
Splenomyelogeuous  leukemia,  387. 
Splenomegaly  without  anemia,  382. 

syphilitic,   accompanied   by   secondary   ane- 
mia, 382. 
malarial,   382. 
tuberculous,  383. 
Splitting  of  the  uterus,  620. 
Sternum,  tuberculosis   of,  203. 
Stomach,  carcinoma  of,  and  gastric  ulcer,  480. 
dilatation   of,  461. 
examination,  chemical  tests,  434. 

("occult     blood")     in     gastric     ex- 
tracts or  feces,  438. 
chymilication,  436. 
color,  436. 

diagnostic    significance     of    the    microor- 
ganisms in  gastric  contents,  446. 
estimation  of  total  acidity,  437. 
of  acidity  method,  436. 
of   the  secretory  activity   of  the  stom- 
ach, 435. 
ferments,  test  for,  pepsin,  Wett  's  method. 

443. 
gastric  function,  examination  of  stomach 

tube,  434. 
interpretation  quantity,  436. 
lactic   acid,  tests  for,  442. 
microscopic    examination    of    gastric    ex- 
tracts,  446. 
motilitv,     estimation     of,     interpretation, 

434. 
organic  acids,  436. 

peptid    splitting   enzymes    in    gastric    ex- 
tracts, tests  for,  443. 
qualitative   estimation   of   acidity,   436. 
rennin  and  its  zymogen,  test  for,  443. 
surgery  of  the.  431. 
test  for  bile.  446. 
tryptophen  test.  444. 
X-ray  method,  435. 

Wolif -Junghan  's  test  for  soluble  albumin 
(used  to  differentiate  malignant 
from  benign  achylias),  444. 


functions  of,  432. 
ulcer,  acute,  chronic,  460. 
Strangulated  hernia,  after-treatment,  377. 
cutting  the  constricting  ring,  375. 
determining   the   ^•itality  of  the  strangu- 
lated gut,  375. 
differential  diagnosis,  372. 
etiology,  373. 
in  children,  trusses  in,  366. 

technique,  366. 
operative  technique,   374. 

preparation,    371. 
precautions,  374. 
prompt     operative     measures     necessary, 

370. 
prognosis,  370. 

resection  of  gangrenous  portion,  376. 
removal  of  bowel  contents,  376. 
symptom  resume,  372. 
treatment,  373. 
taxis  in,  371. 
type  of  case,  370. 
Strictured  urethra,  resection  of,  597. 
Subdural  abscess,   117. 
Surgeon,   clinical  experience   of,   17. 
Surgery,  modern  military,  745. 
Surgery  of  the  abdomen,  cathartics,  diuretics, 
227. 
preparatory   treatment,   227. 
traumatism,    gaseous    distension,   230. 
of  the  esophagus  and  stomach,  406. 
of  the  stomach,  general  considerations,  431. 
Surgical  hospital,  the,  787. 
Suture  material,  non-absorbable,  84. 
Suturing  of  deep  wounds,  82. 
of  superficial  wounds,  83. 
absorbable,  84. 
Sutures,  superficial,  principles  of,  83. 

tension,  83. 
Syringe,  exploring  by,  condemned,  18. 


Tendon  sutures,  705. 

transplantation,  706. 
Testicle,  tumors  of,  606. 
Theory  vs.  practice  in  surgical  methods,  59. 
Thyroglossal   cyst,   153. 
Thyroid  gland,  malignant  growths  of,  results 

of  operations  unsatisfactory,  165. 
Toe-nail,  ingrown,  732. 

Tongue,  carcinoma,  glandular  invasion  in,  141. 
complication.  142. 

excision  of  carcinoma  of,  141. 
Tonsils,   avenues   of  infection,   144. 

excision    of.   complications,   144. 
hemostasis,  145. 

technique  of  operation,  144. 
Torticollis.  175. 

spasmodic,   176. 
Trachea,  injury  to,  151. 
Tracheotomy,  176. 
Traumatism   in   operating,   26. 
Transfusion  of  normal  blood,  47. 

of  blood,  an  indirect  method  for  the,  734. 
Transplantation   of   the   ovaries,    627. 

of  bone,  688. 


INDEX 


817 


Trifacial  neuralgia,  injection  of  alcohol,  122. 
internal  treatment  and  dietary,  122. 
osmic   acid  injections,   123. 
technique   of   alcohol   injection,   123. 
Tubercular    glands    of    neck,    causative   influ- 
ences, 166. 
direction  of  infection,  166. 
Tuberculin,    constitutional    manifestations    of 
reaction,   36. 
dosage  of,  37. 

local  evidence  of  reaction,  36. 
the  ophthalmic  test   (Wolff-Eisner  and  Cal- 

mette)   or  conjunctival  reaction,  38. 
test,  the  subcutaneous,  34. 
Tuberculosis  of  joints,  707. 
of  hip  joint,  708. 
of  shoulder,   elbow   and   other  large  joints, 

701. 
of  the  ribs,  198. 
of  the  sternum,   203. 
of  sacro-iliac  joint,  711. 
of  the  kidney,  551. 

of  lung,  unilateral,  operative  treatment  by 
total  mobilization  of  the  chest  wall, 
by   means   of   thorocoplastic,  pleuro- 
pneumolysis,  191. 
in  regard  to  surgical  operations,  23. 
Tuberculous  glands  of  neck,  166. 
after-treatment  important,   171. 
clinical  instance,  167. 
general  treatment,   168. 
splenomegaly,    383. 
technique,  169. 

tonsils  and  adenoids,  removal  of  in,  170. 
use  of  Beck's  bismuth  paste,  172. 
Tumors,  diagnostic  palpation  condemned,  17. 
examination  of,   condemned,   17. 
non-malignant,  of  bone  and  cartilage,  724. 
of  the  breast,   205. 
of  the  bladder,  593. 
of  the  chest,  203. 
of  the  jaw,  technique  of  operation,  137. 

general  prognosis,  171. 
of  the  lip,  146. 
of  the  ovaries,  609. 
of  the  testicle,   606. 

Ulcer  of  the  stomach,  acute,  chronic,  460.  X-ray  burns,  696. 


Umbilicus,  infection  of  the,  treatment,  403. 
Ununited   fractures,   clinical   history    of   case, 
677. 
technique    of  repair,   667. 
Ureter,  calculus  of,  565. 

excision  of,  564. 

section  of.  Van  Hook  operation,  566. 
Ureteral  fistula,  permanent,  567. 
Urethra,  excision  of,  656. 

resection  of  strictured,  597. 

rupture  of,  596. 
Urethrotomy,  593. 
Uterus,  adhesions  about,  619. 

carcinoma  of,  628. 

prolapsus  of,  642. 

splitting  of,  620. 
Unna's  paste  cast,  699. 

V 

Vaginal  hysterectomy,  628. 

Varicocele,  583. 

Varicose  veins  of  the  lower  extremities,  697. 

ulcers,  701. 
Vas    deferens,    uniting    of    after    accidental 

severing,  605. 
Vasectomy,  597. 
Ventral  hernia,  etiology,  353. 
principles   of   cure,   357. 
following     abdominal    surgery,    type    of 

case,  353. 
operative  technique,  356. 
Vesicocele,  653. 

after  treatment  of,  656. 
prognosis  of,  656. 
Vesico-vaginal  fistula,  prophylaxis,  technique, 

and  prognosis  of,  657. 
Volvulus,  326. 

W 

Widal  test,  44. 

"Wounds,   aseptic,  after-treatment  of,   85. 

clean,    becoming    infected,    after-treatmont 
of,  86. 

septic,  after-treatment  of,  85. 


X 


/-A 


^Ul  K 

COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx)  *•    £}  lUlu 

RD32  0C3C.1  .^'O 

A  new  manual  ofsiMier 


>cH  e/*c 


^^^ 


